2011-12
MEDICINE AND SURGERY CLINICAL ATTACHMENTS
SCHOOL OF MEDICINE
UNIVERSITY OF DUBLIN,
TRINITY COLLEGE DUBLIN
Table of Contents
Introduction & Learning Strategies 3
Reading List 5
Guide to getting the most out of 6
your placements
Clinical Medicine 10
Clinical Surgery 40
Appendix 1 75
Specialised History Templates
Appendix 2 77
Principles of Surgical Investigation and
Peri-operative Care
Appendix 3 80
Blank Weekly Timetable
2 | Clinical Attachments
YEAR 3 CLINICAL ATTACHMENT SCHEME
Welcome to your Clinical Attachment Programme in Medicine and Surgery. You will
experience six months of clinical exposure between today and the end of June. The
sequence of the attachments have been planned to give you exposure to both general and
specialised Medicine and Surgery.
You are assigned to Clinical Medicine and Clinical Surgery for 3 months each. ENT/
Ophthalmology have been relocated to this year and will contribute as one of the months of
Surgery.
Attachment to the hospital departments of clinical medicine and surgery occupy four week
attachments throughout the scheduled clinical teaching year.
Medicine
1
ENT/
Medicine
2
OPHTH
Clinical
Attachments
Surgery 2
Affiliate
Surgery 1
Rosters for each student will involve attachment to clinical teams at Tallaght, St James’s,
Naas and Peamount Hospitals. In addition, this module involves regular small-group
tutorials which will be arranged by individual tutors within the Hospital Attachment time,
plus formal teaching sessions during the teaching blocks. Assessment of this module is
continuous, with periodic examinations and evaluations of clinical competence each
contributing towards the final Fifth Year marks in clinical medicine and surgery. There will
also be a Clinical Skills development programme run throughout the year, a detailed
description will be provided at the beginning of Michaelmas term.
This booklet is designed to assist you while you are attached to your specific teams. Each
speciality has outlined the objectives, under the headings of knowledge, skills and
professional behaviour, that you are expected to obtain while on attachment. The
assessment format is also provided. Objectives might be different for the same specialty at
two different sites- this reflects the patient profiles attending each site. Take a look at what
the other site’s objectives are for your placement to see topics which you should read
around. In appendix 2, there is a generic blank timetable. When you first meet the
3 | Clinical Attachments
consultant/ SpR who will supervise you, take a photocopy and fill it in with the team’s
timetable of what you are expected to attend, and fill in the learning objectives in your
logbook. If you are having difficulty finding your consultant, give their secretary a ring and
find them in clinic. You will be expected to draw on the clinical skills that you developed
last year and expand them further in accordance with the directions included within.
Learning strategies for Student Centred Learning
Dr Claire Donohoe, Clinical Lecturer
As you progress through your medical school career, the focus on learning becomes
increasingly student centred. By this we mean, you become responsible for defining your
own learning objectives and ensuring that you fulfil your goals. The Departments of
Surgery and Medicine are eager to assist you with this and hopes that you will find your
clinical attachments and tutorials stimulating and informative. The third medical year is a
critical time to grasp the principles of Medicine and Surgery, and the basic techniques
involved in taking a focussed history and performing a physical examination. As part of the
progression towards a more student centred approach, you are expected to define your
learning objectives: i.e. you should make a plan of the specific cases which you would like
to see and present, surgeries you would like to attend and reading you aim to cover. The
Departments of Surgery and Medicine suggest that you make a learning plan prior to each
clinical attachment and discuss this with members of the clinical team. This should be
recorded in your logbook. Remember the more knowledgeable you have prior to
commencing your attachment and the more you are involved with the clinical team, the
more you will gain from the experience.
We suggest that you look through this study guide and through the web resources to help
you identify areas in which you will be required to become knowledgeable. You should
identify key, common conditions that are seen within your placements, and make sure you
see patients with these conditions, and that you discuss them with tutors/ supervisors. You
should then be able to integrate the knowledge from lectures with the clinical conditions you
are seeing.
We are aware of the significant input in the form of lectures provided by other departments
during the third medical year. We advise you that you see your clinical attachments as the
ideal time in which to integrate the knowledge you are gaining regarding
pathology/pharmacology/medicine and so on, and to see how it is applied in the clinical
setting. The sooner you integrate all this knowledge together, the easier you will find it
remember disparate elements of the course as a whole and the lesser the burden of new
information which you will encounter in your forthcoming medical years.
You should prioritise time spend on wards or in clinics ahead of reading time as this is
where the majority of your learning experiences during clinical attachments occur. Despite
this, you will also be expected to supplement your clinical experience with reading and selfdirected learning. You should aim to develop skills in “on-site” learning from pocket books
or brief periods spent reading during the working day as well as during un-rostered time.
4 | Clinical Attachments
Reading List, Medicine:
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Kumar and Clark’s CLINICAL MEDICINE (Saunders, 5th Edition, August ‘05)
Clinical Examination: A Systemic Guide to Physical Diagnosis by Tally &
O’Connor
Oxford Handbook for Clinical Medicine
Medicine at a Glance
Davidson Text Book of Clinical Medicine
Handbook of Acute Medicine
BNF
Pharmacology at a Glance
Essentials of Clinical Medicine (Saunders, 3rd Edition, pocket)
ECG Made Easy
Hunter. Various Atlases of Dermatology
Rook /Wilkinson /Ebling -- Textbook of Dermatology.
Additional Reading:
o The Oxford Textbook of Clinical Medicine
o Harrison’s Principles and Practices of Medicine
o Scientific American Medicine
Reading List, Surgery:
Physical signs and examination:
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Browse’s introduction to the symptoms and signs of surgical disease
Burnand,Hodder Arnold
Hamilton Baileys demonstration of physical signs in clinical surgery
Bailey, Lumley, Hodder Arnold
MacLeod’s Clinical examination
Nicol, Churchill Livingstone
Textbooks:
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Clinical Surgery
Cuschieri, Hennessy, Greenhalgh, Rowely, Grace, Blackwell Science
Essential Surgery
Burkitt, Quick, Deakin, Churchill Livingstone
Surgery at a Glance
Grace, Pierce, Wiley-Blackwell
Pocket books and self-assessment material
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Washington Manual of Surgery
Lippincott, Williams and Wilkins
Oxford handbook of Surgery
Oxford university press
Surgery
Churchill Livingstone
Surgical Recall
Blackbourne, Lippincott, Williams and Wilkins
5 | Clinical Attachments
Guide to How to Get the Most of Your Attachment
in Year 3
Dr Matthew Phillips, Clinical Lecturer
Triona Flavin, Clinical Skills Tutor
Dear Student,
Clinical placements can be the best learning experiences of your whole life, but sometimes
it is very easy to feel lost and aimless when you hit a new placement. This is just a short
guide of tips to help you get the most out of your placement. Many people feel unsure of
their role, and in this way do not manage to get much out of their placement. Remember,
everyone you meet from healthcare assistant to consultant is incredibly busy and worried
about caring for their patients properly. If you approach them with enthusiasm and perhaps
the offer of help, then you will reap the rewards. Do not underestimate your ability to help
whilst at a placement; re-siting a cannula for a nurse when she has been waiting for the
doctor for an hour will make you popular with the nurse, the doctor and , most importantly,
the patient. Not only do you gain popularity, you gain extra practice at this clinical skill.
When you get to your OSCE, a plastic arm is not going to cause you any trouble.
There is no such thing as a bad placement- you can make of any placement what you want.
If you want to do gastroenterology, but get haematology, this is the perfect opportunity to
understand iron metabolism, the different types of anaemia and how to examine for a spleen
correctly. Equally, a placement in orthopaedics will enable you to learn principles of
general surgery if you look at principles of pre and post operative care, haemostasis and
fluid balance rather than just the operations themselves. Make your placement work for
you- the onus is on you to get what you can out of it.
The People
Doctors
The firm / team to which you are attached. Everyone will be busy looking after their
patients, getting to this place and that, so where do you fit in? The best advice is to get
involved. Whoever your consultant is, get to know their patients by reading the notes
before the ward round. Follow the intern- they will always be grateful for someone to help
them take blood, fill in forms etc. Although this may appear boring, you will gain excellent
skills (and therefore OSCEs will be a doddle), and you will be contributing to the team.
When the intern/SHO of your team is on call, ask if you can shadow them. You will pick up
first-hand experience of the unwell patient. Exams really are easy once you have seen a real
life chest pain (and done the patient’s ECG and taken their ABG). In addition, doctors are
just people the same as everyone. They want to teach people who look eager to learn and
who are joining in the workload. It is hard to help anyone, who doesn’t know what help
they need.
6 | Clinical Attachments
Nurses
They are everywhere, and yet mysterious to most medical students. They have a massive
wealth of skills you can pick up, and if you look on the ward, you’ll see all the thank you
cards are to the nurses. When on the ward, be polite to them, and don’t get in their way.
Ask permission before you clerk a patient; you’ll save yourself time too, because the nurses
will know when the patients are at scans etc. In addition, the auxiliaries do all the skills you
will be admired for if you can perform competently… if you can’t take a full set of obs, ask
them to show you how; if you’ve never fed a patient, ask if you can watch how it’s doneand do it-and most vital of all, moving a patient around and maintaining their dignity is a
special skill, and the auxiliaries are the best at it.
Phlebotomists
Why not shadow one and take bloods all morning? You’ll always find a vein after that. As
an intern (and in finals) you’ll know which test goes in which bottle.
Physiotherapists
Our most athletic colleagues. You can learn mobility/ stair assessments of these folks, as
well as how to examine the respiratory system well.
Occupational therapists
If you enjoy making lives better, you should see what these people do. If a patient can’t do
something, such as get in their house, cook their food, clean themselves, the occupational
therapists will know a way to make it happen for the patient.
The Places:
Medical placements:
Medicine is a very diverse specialty. You will encounter patients from the stable
rheumatoid arthritis patient, to the patient in cardio-respiratory arrest. So, here are some
things you should aim to encounter, in whichever specialty you’re visiting:
Consultations
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Ward rounds (both SHO led and consultant led)
Consultant outpatient clinics
Consultations where bad news is given
Taking your own history and examination for new referrals to OPD
Taking your own history and examination for acute admissions (only after a doctor
has cast an eye to see the patient is stable)
7 | Clinical Attachments
Skills under appropriate supervision
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ABGs
Reading X-rays
Taking bloods
Taking and reading ECGs
Catheterisation
Seeing death certificates/ prescriptions being written
Life support
Skills to see
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Exercise tolerance testing
Bone marrow trephine
Central line placement
Abdominal paracentesis
Chest tap
Chest drain insertion
Lumbar puncture
Surgical Placements
Surgery is equally diverse, but even general surgeons do not cross cover for very specialised
work, such as orthopaedics.
Consultations
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Ward rounds (both SHO led and consultant led)
Consultant outpatient clinics
Consultations where bad news is given
Taking your own history and examination for new referrals to OPD
Taking your own history and examination for acute admissions (only after a doctor
has cast an eye to see the patient is stable)
Seeing consent being discussed and taken
Skills to do under appropriate supervision
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Catheterisation
Taking and reading ECGs
Wound examination/ dressing (ask the nurses)
Siting IV cannulas
Reading abdominal x-rays and orthopaedic x-rays
Taking an ankle-brachial pressure index
Suturing
Scrubbing for theatre
Assisting in theatre
Examination skills- especially lumps and bumps.
8 | Clinical Attachments
Skills to see
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Fracture reduction/ dislocation reduction
Minor surgery
Major surgery
Anaesthetics
Anaesthetics requires a lot of cool- make sure you keep your voice down when you’re
attached to these teams, especially in the anaesthetic room.
Consultations
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Anaesthetic assessments
Pre-op checks
Intensive care wards rounds
Post-op recovery room
Skills to do under appropriate supervision
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Catheterisation
IV Cannulation
Laryngoscopic visualisation of the vocal cords
Skills to see
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Lumbar puncture
Spinals
Central line placement
Intubation
Finally…
The skills tutors and clinical tutors are always there to help and advise. Your logbook can
be used to record all of your efforts so you can see how far you have come in the third year.
And remember, enjoy your placements, the more you put in, the more you will get out.
Matthew Phillips
Triona Flavin
9 | Clinical Attachments
Clinical Medicine
Age Related Health Care/ 11
Medical Gerontology
Cardiology 13
Dermatology 15
Endocrinology 18
Gastroenterology 19
General Medicine/ 21
Clinical Pharmacology
General Medicine/ 22
Respiratory
GU Medicine & 23
Infectious Diseases
Haematology 24
Medical Oncology 26
Nephrology 27
Neurology 29
Palliative Care 30
Physical and Rehabilitation 31
Medicine
Including Peamount and the NRH
Respiratory 32
Including Peamount
Rheumatology 37
Useful Contacts 38
10 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Age-Related Health Care
Prof Desmond O’Neill, Dr Ronan Collins, Dr Tara
Coughlan, Dr A O’Driscoll
AMiNCH
3
OBJECTIVES OF ATTACHMENT
During your month our aim is twofold. The first is an approach to general medicine in older
people: if you find less than five diagnoses in a patient over the age of 75, you are missing
some! This is not an exercise in diagnostic stamp collecting, but rather the detection and
prioritization of multiple diseases in older people which is one of the cornerstones in
geriatric medicine.
The second area is of emphasis on function and also the working of the multi-disciplinary
team. By function we mean an emphasis on medical, physical and emotional factors which
lead to problems with functions like mobility, continence, intellectual function etc. It is
these factors which are often complex and represent a challenge to the diagnosis and
management which are the most important ones in terms not only in the patient’s quality of
life but also with their length of stay in the hospital. To this end Age-Related Health Care
works in an inter-disciplinary fashion with doctors, nurses, physiotherapists, speech
therapists, occupational therapists, social workers, psychiatry, chiropody and clinical
nutrition services. You will also have exposure to the first Acute Stroke Service in Ireland,
as well as to a Rapid-Access TIA Clinic. We also ensure a strong link with the community
and do this through close communication via a visiting sister and referral to community
based rehabilitation teams, the District Care Unit.
On arrival to the ward you will be assigned a number of patients to clerk and follow their
progress, as well as seeing new patients as they arrive. During your month with us you will
be expected to present cases on a weekly basis from the wards and as a help to
understanding the assessment of function you will be expected to carry out the following
screening instruments on patients:(i)
Mini-Mental State Examination (cognitive function)
(ii)
Geriatric Depression Scale (depression screening scale)
(iii) Barthel (activity of daily living index)
There are medical and interdisciplinary journal clubs (Wednesday 8.30 am and Friday 12.30
pm), as well as an X-ray conference (Thursday 9.30 am)
Tel +353 1 414 3215 Fax +353 1 414 3244
Email: arhc@amnch.ie
e-resource: www.ageandknowledge.ie: Here you will find our ‘AgePages’ on common
conditions in later life, as well as a medical/medical humanities reading list on medicine for
older people.
11 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Medical Gerontology
Prof Davis Coakley, Prof. J. Bernard Walsh, Dr Conal
Cunningham, Dr Miriam Casey, Dr Joe Harbison
SJH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Knowledge:
- Review of systems examination
- Multi-system disease and be aware of the multi-factorial causes of illness
- Major focus on cardiovascular, CNS, Parkinson's Disease and mobility
- Syncope, Falls, Bone Protection and Osteoporosis, Memory Assessment
- Rehabilitation esp. stroke rehabilitation and the close working involvement
of the multidisciplinary team
- Family and social components of illness
Technical Skills/Procedures
- General History and Physical Examination of all systems
- Comprehensive cognitive assessment
- CNS examination
- Cardiovascular systems
Management and Professional Behaviour:
The student is:
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Expected to understand and experience at first hand the clinical management of
cases and the post discharge follow up.
To attend consultant and registrar ward rounds and case conferences.
To experience and work with multidisciplinary teams
To attend general and specialised clinics (Bone, Falls and Memory)
To attend all X-Ray and teaching conferences including lunch time journal clubs
To attend and experience the day hospital during allocated periods
To be able to fully relate to patients and work closely with other professionals
To attend all tutorials (including Final Med tutorial sessions)
At the end of this attachment the assessment format will include:
 Bedside examination of cases
 Clinical discussion of major cases
12 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Cardiology
Dr. David Mulcahy, Dr. David Moore, Dr. Vincent Maher, Dr
Deirdre Ward, Dr Bryan Loo
AMiNCH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to:-
Learn the physiology of the cardiovascular system
Recognise and describe the signs and symptoms of major cardiovascular disease
such as myocardial ischemia, infarction and hypertension.
Gain an understanding of the Bayesian or probabilities-based approach to diagnosis.
Gain an understanding of the concept of evidence based medicine.
Develop a working knowledge of the range of services provided, investigations and
therapies provided by a department of cardiology.
Develop knowledge of basic clinical pharmacology and appreciation for the need for
generic prescribing.
Learn the concept of total cardiovascular risk estimation and its practical importance
in patient management. A working knowledge of the department of cardiac
rehabilitation.
Technical Skills/Procedures
Be able to:- Do a complete cardiovascular assessment including:- Full medical history.
- Examination of peripheral pulses for rate, rhythm and quality.
- Take blood pressure.
- Locate the apex beat.
- Observe of the JVP.
- Palpate for thrills.
- Identify the first and second heart sounds.
- Recognize mitral, aortic, pulmonary and tricuspid murmurs and assess their timing
and intensity.
- Record an ECG and identify of common abnormalities.
Management and Professional Behaviour.
The student will always:
- Present a clean and tidy appearance.
- Demonstrates punctuality, reliability, and willingness to co-operate with other team
members.
- Empathise with patients and shows consideration towards patients at all times.
- Demonstrates a capacity to act appropriately on his/her own initiative.
- Demonstrates resourcefulness and flexibility in work practice.
At the end of this attachment the assessment format will include:
 Presentation of a patient with a recent myocardial infarction.
 Interpretation of cardiac aspects of chest x-ray.
 Interpretation of electrocardiograph.
 Discussion of the use of drugs in the management of hypertension.
 Advice to be given to a patient to ensure healthy lifestyle practices.
SPECIALTY:
Cardiology
13 | Clinical Attachments
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Dr Peter Crean, Dr Brendan Foley, Dr Ross Murphy,
Dr Niall Mulvihill
St James’s Hospital
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
- Physiology of the Cardiovascular System.
- Symptoms and Signs of Cardiovascular Disease.
- Ability to take a history, perform physical examination and present findings to team
members.
- Observation of diagnosis and treatment of cardiovascular emergencies and acute
admissions.
- Some knowledge of evidence based therapies.
- Observation of non-invasive and invasive diagnostic procedures.
Technical Skills/Procedures
Be able to
- Medical History
- Examination of the cardiovascular system.
- Assessment of pulse, JVP, BP.
- Location of apex beat and precordial palpation.
- Auscultation of heart sounds and lungs.
- Recognition of murmurs.
- Apply scientific knowledge to clinical problems.
- Familiarity with commonly used cardiovascular drugs.
Management and Professional Behaviour
The student should show:
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Regular attendance.
Punctuality.
Proper relationship with patients and staff.
Flexibility.
Initiative.
At the end of this attachment the assessment format will include some of the
following: Continuing assessment of the above skills set.
 Presentation of a patient to staff member.
 Interpretation of ECG.
 Some knowledge of commonly used cardiovascular drugs.
SPECIALTY:
14 | Clinical Attachments
Dermatology
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Dr Maureen Connolly, Dr AM Tobin
AMiNCH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to:Know
- A working knowledge of the common skin diseases, how to describe them, how to
diagnose them and basic management.
- Familiarity with contact dermatitis.
- Investigation and treatment of inflammatory skin disease with light treatment and
systemic therapy.
- Basic paediatric dermatology problems.
- Introduction to skin surgery.
Technical Skills/Procedures
Be able to:- Recognise the common dermatological abnormalities.
- Describe the range and appropriate use of investigations.
- Acquire the practical skills of dressing and wound care.
- Understand the processes involved in patch testing.
- Describe the common dermatological, surgical procedures as a result of direct
observation.
Management and Professional Behaviour.
The student shows:
- Attention to dress, demeanour and punctuality.
- Careful attention to patient needs.
- Good working relationship with team members and peers.
- Resource and flexibility in working situations and emergencies.
- A capacity to take responsibility as appropriate to status.
- A capacity to do self study and lateral thinking.
- Overall impresses as an effective practitioner (global judgement)
At the end of this attachment the assessment format will include
 Selection, presentation and discussion of a case seen during the attachment
e-Resource: http://www.derma.med.uni-erlangen.de/en_index.htm
SPECIALTY:
15 | Clinical Attachments
Dermatology
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Dr Louise Barnes, Dr Rosemarie Watson, Prof. Alan Irvine
Dr. Patrick Ormond
SJH, Department of Dermatology, HOSPITAL 7, Ph
2102/2103
Registrar’s Bleeps – 973/978.
3
Programme for students attached to the Dermatology Department:
1. Introduction to the department
2. Aims of programme
3. Time table of activities
4. Aids to learning dermatology
5. Assessment
1. INTRODUCTION TO THE DERMATOLOGY DEPT.
On day one of your Dermatology attachment, please come to the Dermatology department
at 9.00am to meet the team or bleep 978 or 973. Telephone extensions of the department
are 2102, 2103 and 4089.
The Department of Dermatology is in hospital 5, the Health Care Centre (HCC). The UVL
room, the registrar’s office and the minor theatres are in the first part of the HCC. The
secretaries and consultants offices are just beyond there (follow a narrow corridor)
All dermatology outpatients are held in suite 5.
Laser clinics are held upstairs in hospital 7.
Dr Watson and Prof. Irvine also work in Our Lady’s Hospital for Sick Children, Crumlin.
Please make a special effort to attend the academic Wed am session which takes place in
one of 3 venues. Speak to the registrars about where it is on and how to get there.
Welcome to the dermatology department. It is hoped that you will both enjoy and
learn the basics of dermatology from your brief period with the department. This may
be your last exposure to clinical dermatology prior to your clinical finals and it is vital
that you use your time in the department well to learn the fundamentals of diagnosis
and treatment of common skin disorders. Every doctor will encounter some aspect of
skin disease in his or her daily practice and a basic knowledge is essential.
2. AIMS DURING PLACEMENT:
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To be able to recognise common skin conditions
To learn the terminology used to describe skin conditions and to be able to use it
effectively
To learn the basic classifications of skin disease, in particular to develop an
understanding of the difference between primary and secondary lesions.
To be able to formulate an investigation and treatment plan for common skin disorders.
To be aware of the practical skills of dressing and wound care, patch testing and
dermatological surgery.
To become familiar with the principles of topical skin therapy.
TOPICS TO COVER:
16 | Clinical Attachments
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Making a dermatological diagnosis
Making a dermatopathological diagnosis
Papulosquamous disorders
Disorders of Keratinisation
Blistering disorders
Disorders of pigmentation
Skin cancers
Disorders of hair and nails
Cutaneous manifestations of internal malignancy
Cutaneous manifestations of connective tissue disease
Cutaneous manifestations of metabolic disorders
Primary cutaneous infections.
Drug reactions.
Clinical histological correlations.
Treatment of dermatological disorders- topical therapies, systemic treatments and
phototherapy.
5. ASSESSMENT
 As you know you are requested to present a case to the consultant or registrar during
your period with the team. Ask for help to select a patient.
e-Resource: http://www.derma.med.uni-erlangen.de/en_index.htm
SPECIALTY:
17 | Clinical Attachments
Endocrinology
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Dr. J. Gibney, Dr J Barragry
AMiNCH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
- The nature of endocrine glands in general and to be able to discuss the role of
hormones and the hypothalamic / pituitary / endocrine axis and feedback loops.
- The normal physiology and anatomy of the pancreas and thyroid glands
- The aetiology, clinical features and management of (a) Type 1 and 2 Diabetes (b)
hyperthyroidism and hypothyroidism (c) goitre and thyroid lumps (d) pituitary
disorders including Cushing’s disease and acromegaly (e) osteoporosis (f) common
reproductive disorders such as polycystic ovary syndrome, (g) endocrine
hypertension (h) hypercalcaemia and hypocalcaemia
Technical Skills/Procedures
Be able to
- Take a full medical history with particular emphasis on the signs and symptoms and
relevant background history associated with a) Diabetes Mellitus b) hyperthyroidism
and hypothyroidism c) thyroid lump, d) common reproductive disorders such as
poycystic ovary syndrome e) osteoporosis
- Do a physical examination of a patient with a) Diabetes Mellitus b) hyperthyroidism
c)hypothyroidism and d) thyroid lump
- Explain the physiological principles underlying common endocrinological
investigations such as thyroid function tests, short synacthen test, insulin tolerance
test and dexamethasone suppression test.
Management and Professional Behaviour
The student is
- Present punctually and properly dressed and remains with the team for full days
unless otherwise scheduled for academic activities.
- Aware of the particular needs of each patient, has an empathy with their situation,
and an ability to manage their treatment having negotiated with them as to desirable
outcomes.
- Has a good relationship with team members, peers and associated professionals.
- Shows some evidence of resourcefulness and flexibility in the workplace.
- Shows some capacity for taking responsibility appropriately and for exploring
interesting leads which arise during case discussion
At the end of this attachment the assessment format will include some of the following:
 Case presentation of diabetic or thyrotoxic patient.
 Discussion on complications of diabetes and thyroid diseases.
 Interpretation of laboratory results
18 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Gastroenterology
Prof McNamara, Dr. Ryan, Dr. Breslin
AMiNCH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to:Know
- The physiology of the gastrointestinal tract.
- Recognise signs and symptoms of gastrointestinal tract diseases.
- Understand in detail the common GI diseases such as GORD, PUD, dyspepsia,
irritable bowel disease, inflammatory bowel disease, liver disease, the various forms
of GI cancer.
- A working knowledge of the range of services, investigations and therapies available
in gastroenterology.
Technical Skills/Procedures
Be able to:- Take a comprehensive medical history.
- Do a complete GI assessment including palpating the abdomen for tenderness or
masses, palpating the liver and spleen, palpating the kidneys and assessment of
ascites.
- Basic interpretation of common radiological and laboratory gastrointestinal
investigations including liver profile and abdominal x-rays.
- Observe and describe the procedures of OGD, Colonoscopy, ERCP, and EUS,
Double Balloon Enteroscopy and Capsule Endoscopy.
Management and Professional Behaviour.
The student always:
- Well dressed, punctual.
- Alert to patient needs and sensitivities.
- Able to establish a good working relationship with team members and peers.
- Demonstrates resourcefulness and flexibility in work practice.
At the end of this attachment the assessment format will include: Presentation of a patient’s history and discussion of further management.
 Interpretation of liver profile.
 Interpretation of endoscopy results.
19 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Gastroenterology/Hepatology
Prof Dermot Kelleher (Gastro)
Dr PW Napoleon Keeling (Gastro)
Dr Nasir Mahmud (Gastro)
Dr Susan McKiernan (Hep)
Prof Suzanne Norris (Hep)
SJH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to:Know
- The physiology of the gastrointestinal tract and the hepatobiliary system.
- Recognise signs and symptoms of gastrointestinal tract, hepatic and biliary diseases.
- Understand in detail the common GI diseases such as GORD, PUD, dyspepsia,
irritable bowel disease, inflammatory bowel disease, liver disease, the various forms
of GI cancer.
- A working knowledge of the range of services, investigations and therapies available
in gastroenterology and Hepatology.
Technical Skills/Procedures
Be able to:- Take a comprehensive medical history.
- Do a complete GI assessment including palpating the abdomen for tenderness or
masses, palpating the liver and spleen, palpating the kidneys, assessment for the
ascites.
- Basic interpretation of the liver profile.
- Observe and describe the procedures of OGD, colonoscopy, ERCP, and EUS.
Management and Professional Behaviour.
The student always:
- Well dressed, punctual.
- Alert to patient needs and sensitivities.
- Able to establish a good working relationship with team members and peers.
- Demonstrates resourcefulness and flexibility in work practice.
At the end of this attachment the assessment format will include:
 Presentation of a patient’s history and discussion of further management.
 Interpretation of liver profile.
 Interpretation of endoscopy results.
20 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE :
General Medicine/Clinical Pharmacology
Dr B Silke, Dr. M. Barry, Dr M Hennessy
St. James’s Hospital
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Knowledge
-
Systems examination
Common medical conditions
Medication Safety, Adverse Drug Reactions
Pharmacoeconomics – an introduction
Hypertension
Common lipid disorders.
Technical Skills/Procedure
-
General history and physical examination
Blood pressure recording
Interpretation of ambulatory blood pressure recordings
Check prescription charts
Interpret lipid profiles
calculate cardiovascular risk
An understanding of arterial stiffness
Management and Professional Behaviour
- Be present each day properly dressed for professional activities.
- Show empathy and understanding of patient needs
- Work as members of team including undertaking simple tasks
- Visit the Library and do at least one topic research.
At the end of this attachment the assessment format will include:
 Review student log of respiratory firm activities
 Presentation of cases both written and at bedside.
21 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
General Medicine/ Respiratory
Dr. D. O’Riordan
SJH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
- acquire knowledge of basic anatomy and physiology of the respiratory system, how
to take a good respiratory history, how to assess and manage common respiratory
illnesses, how to interpret ABG’s, PFT’s and CXR’s.
-
Also will be exposed to a broad spectrum of general and acute medicine and will be
expected at the end of the rotation to be knowledgeable in the management of some
of the common acute medical presentations such as asthmatic attacks, pneumonia,
exacerbation of COPD, exacerbation of CCF, cellulitis, diabetes complications,
sepsis, stroke, pulmonary embolism.
-
Be familiar with management of common respiratory illnesses including COPD,
asthma, pneumonia, P.E., Lung cancer, TB, respiratory failure.
Technical Skills/Procedures
Be able to:- interpretation of blood gases, of CXR’s, of pulmonary function tests
- basic knowledge of the theory and practice of non invasive ventilation
Management and Professional Behaviour
The student shows:- Ability to take a good respiratory history and do respiratory clinical examination.
- Interact with the team during the rotation.
- Display empathy, professional behaviour, understand the broader implications of an
illness for the patient in terms of physical, mental, social issues etc.
At the end of this attachment the assessment format will include







medical knowledge
clinical skills
punctuality
attendance
level of interaction with the team
professionalism in dealing with patients
empathy
22 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
Genitourinary Medicine & Infectious Diseases
Prof Mulcahy, Prof Bergin, Dr Lyons
SJH
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
- Basic principles of infection & immunity
- Management of immunosuppressed patients & drug misuse issues
- Ability to undertake full sexual health & psychosocial history
- Basic principles of antimicrobrial prescribing
- Clinical presentation & management of :
 community acquired infection eg Bacterial Endocarditis, Sepsis,
complicated soft tissue infection, pneumonia etc
 opportunistic infections of HIVdisease
 principles of antiretroviral prescribing
 sexual health screening
 management of liver failure
 international health infections eg malaria
 Technical Skills/Procedures
Technical Skills/Procedures
- Be able to:
o Phlebotomy + line insertion, taking blood cultures
o ABG
o Gram stain & interpretation
-
Observe and take part in:
o
o
o
o
Bone marrow
Lumbar puncture
Skin biopsies
Liver biopsy
Management and Professional Behaviour
- Full attendance @ weekly schedule
- Continuity of care of at least 2 patients/week
- Attendance @ multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Appropriate dress
At the end of this attachment the assessment format will include




Review student log book
Feedback
Formal assessment as per medical school
Power point presentation (x1) at departmental meeting
23 | Clinical Attachments
SPECIALITY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE:
Haematology
Dr. H. Enright, Dr J. McHugh
AMiNCH
3
OBJECTIVES OF ATTACHMENT:
During this attachment a student is expected to:Know
- Exposure to basic concepts of benign and malignant haematological disorders and
blood count abnormalities.
- Basic understanding of the management of common haematological conditions,
including anaemia, thrombocytopenia, leucopenia, and common myelo- and lymphoproliferative disorders.
- understanding of the basic principles of diagnosis and management of the patient
with neutropenic sepsis
- Basic principles of blood transfusion
- Basic principles of effects of chemotherapy (including side effects)
Technical Skills/ Procedures
- Take a full relevant medical history.
- Do a comprehensive physical examination including the lymphatic system and
detection of splenomegaly.
- Interpret the full blood count and coagulation screen.
- Observe and describe bone marrow sampling procedures.
- Demonstrate a high level of cross infection control awareness and technique.
Management and Professional Behaviour
- Present each day
- Well dressed, punctual and available for as long as is required by the team.
- shows empathy and awareness of patient needs and wishes.
- Takes responsibility, appropriately for his/ her own learning and work practices.
- Relates well to peers and co-workers.
- Demonstrates control, efficiency and resourcefulness in emergency situations.
At the end of this attachment the assessment format will include some of the following:
 Discuss the appropriate investigations of an anaemic patient.
 Present a case of Leukaemia and discuss the treatment plan
 Discuss the likely differential diagnosis of a patient with splenomegaly or
lymphadenopathy.
24 | Clinical Attachments
SPECIALITY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE:
Haematology
Dr Paul Browne, Dr Eilish Conneally, Dr Elizabeth
Vanderberghe
St James's Hospital
3
OBJECTIVES OF ATTACHMENT:
During this attachment a student is expected to:Know:
- the common presenting symptoms of different types of Anaemia.
- the signs and symptoms of Thrombocytopenia.
- signs and symptoms of Myeloproliferative diseases.
- the common presenting signs and symptoms of acute and chronic leukaemia.
- the principles of the diagnosis and management of patients with neutropenia.
- the principles of chemotherapy.
- the principles of blood transfusion.
- the principles of stem cell transplantation.
Technical Skills/ Procedures
- History and Examination of patient with specific reference to the Haematological
disorders.
- Interpretation of ‘Full blood Count’ results and ‘Normal’ ranges.
- Interpret simple Coagulation Screen.
- See normal bone marrow slide
- Learn principles diagnosis of Leukaemia
- Attend peripheral blood stem cell harvest and /bone marrow harvest.
Management and Professional Behaviour
- To attend multidisciplinary ward rounds to understand the complexity of dealing
with patients undergoing intensive therapy and/or transplantation for malignant
haematological disorders.
- Understand sense of fear in patients undergoing complex treatments for life
threatening diseases. Understand ethical issues involved in decision-making. Learn
how to dress, behave and interact with patients.
At The End Of This Attachment




Be able to take a history and examine patient
Be able to interpret ‘Full Blood Count’ and simple Coagulation results.
Be able to look at simply interpret a blood film
Understand the principles and common complications of transfusion of blood and
blood products.
25 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Medical Oncology
Professor Ken O’Byrne, Dr J Kennedy,
St. James’s
Year 3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to:
Know:
- Appreciate the basics of cancer biology.
- Learn how cancer presents and is diagnosed.
- Appreciate the importance of a full tissue diagnosis.
- Understand the staging of cancer and how it guides treatment.
- Understand the psychological and social effects of a cancer diagnosis.
- Gain insight to the multidisciplinary management of cancer.
- Begin to understand oncologic emergencies.
Technical Skills/Procedures:
-
History recording including family history.
Physical examination focused on cancer staging.
Observation of procedures such as aspiration of body fluids, bone marrow sampling
and lumbar puncture with intrathecal therapy.
Undertake venepuncture and siting of IV lines, if sufficiently skilled.
Management and Professional Behaviour:
-
Commit to becoming a full member of team.
Assist NCHD colleagues with patient management as appropriate.
Undertake supervised care of a small number of patients and present these cases on
rounds.
Develop interpersonal skills as applied to patients’ families and colleagues
At the end of this attachment the assessment format will include:
 Review of logbook record of cases and professional development
26 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Nephrology
Dr. Mellotte, Dr Wall
AMiNCH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
- Clinical presentation of renal disease, e.g., proteinuria, hypertension,
haematuria and uraemia.
- Normal values in blood and urine.
- The signs and symptoms of renal failure including dialysis & transplantation.
- The management of acute and chronic renal failure.
- Impact of renal failure on drug handling.
Technical Skills/Procedures
Be able to;
- Take a full and appropriate current and past medical history.
- Discuss the range of clinical investigations available and to understand how they
may be used to inform the differential diagnosis.
- Attend and observe at least 1 haemodialysis session and if possible a renal biopsy.
- Palpate a Renal transplant kidney & a native Kidney
Management and Professional Behaviour
The student is
- Present punctually and properly dressed and remains with the team for full days
unless otherwise instructed.
- Aware of the particular needs of each patient, has empathy with their situation, and
an ability to manage their treatment having negotiated with them as to desirable
outcomes.
- In a good relationship with team members, peers and associated professionals.
- Showing some evidence of resourcefulness and flexibility in the workplace.
- Showing some capacity for taking responsibility appropriately and for exploring
interesting leads which arise during case discussion
At the end of this attachment, the assessment format will include some of the
following;
 Discussion of abnormal blood and / or urine laboratory reports.
 Presentation and discussion of a case currently being treated in the unit.
 An understanding of the principles of dialysis
27 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Nephrology
Dr. Mellotte
SJH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
-
Clinical presentation of renal disease, e.g., proteinuria, hypertension, haematuria and
uraemia.
Normal values in blood and urine.
The signs and symptoms of renal failure including dialysis & transplantation.
The management of acute and chronic renal failure.
Impact of renal failure on drug handling.
Technical Skills/Procedures
Be able to
-
Take a full and appropriate current and past medical history.
Discuss the range of clinical investigations available and to understand how they
may be used to inform the differential diagnosis.
Attend and observe at least 1 haemodialysis session and if possible a renal biopsy.
Palpate a Renal transplant kidney & a native Kidney
Management and Professional Behaviour
The student is
- Present punctually and properly dressed and remains with the team for full days
unless otherwise instructed.
- Aware of the particular needs of each patient, has empathy with their situation, and
an ability to manage their treatment having negotiated with them as to desirable
outcomes.
- In a good relationship with team members, peers and associated professionals.
- Showing some evidence of resourcefulness and flexibility in the workplace.
- Showing some capacity for taking responsibility appropriately and for exploring
interesting leads which arise during case discussion
At the end of this attachment, the assessment format will include some of the
following:
 Discussion of abnormal blood and / or urine laboratory reports.
 Presentation and discussion of a case currently being treated in the unit.
 An understanding of the principles of dialysis
28 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Neurology
Dr McCabe, Dr Murphy
AMiNCH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to:
Know
- In broad outline, the anatomy and physiology of the cerebral hemispheres, spinal
tract and peripheral nervous system.
- To be able to know how to assess the neuro-psychological state simply by using a
mini-mental state testing.
- To understand the indications for the appropriate investigations in neurological
disease.
- To be familiar with the commonly used drugs to treat epilepsy, Parkinson’s disease,
MS and other common neurological disorders.
Technical Skills/Procedures
Be able to:
-
take a full medical history with particular reference to any neurological symptoms.
competently do a basic neurological examination of the cranial nerves, central
nervous system and peripheral nervous system.
recognise the common intracranial structures seen on CT brain and MRI of brainyou may acquire these skills on the ward and by attending the weekly XR meeting
and the neuroscience meeting at Beaumont.
Management and Professional Behaviour.
The student must always:
-
-
Present punctually and properly dressed and remain with the team for full days
unless otherwise instructed.
Be aware of the particular needs of each patient, has empathy with their situation,
and an ability to manage their treatment having negotiated with them as to desirable
outcomes.
Has a good relationship with team members, peers and associated professionals.
Shows some evidence of resourcefulness and flexibility in the workplace.
Shows some capacity for taking responsibility appropriately and for exploring
interesting leads which arise during case discussion. (appropriate reading of
literature etc.)
At the end of this attachment the assessment format will include some of the following: Review of Cranial nerve examination.
 Case presentation and discussion.
 Set up and preparation for lumbar puncture.
29 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE :
Neurology
Dr. Janice Redmond, Dr C Doherty
SJH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know:
- Basic Neuro anatomy.
- Testing for use for EEG, EMG
- Testing for Brain and Spinal imaging.
- Background in Neuropharmacology.
- How to do a Neurologic examination
Technical Skills/Procedures
Be able to:
- Able to take a full history/family review.
- Competently perform a basic neurological exam.
- Be able to know what normal neurophysiological results look like.
- Be able to know what normal Brain and spinal imaging look like.
Management and Professional Behaviour
-
Present punctually and look professional and get integrated with team activities.
Time must be spent with patients in a helpful and constructive fashion.
Background reading is essential.
At the end of this attachment the assessment format will include some of the following;




Cranial Nerve exam.
Mental State exam.
Examination of the peripheral nervous system.
Some understanding of common neurological complaints
30 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE:
Palliative Medicine
Dr Kelly, Dr Higgins, Dr O’Siorain
Our Lady’s Hospice, Harolds Cross
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to know
 Common symptoms encountered in palliative care and their management
 How to manage pain effectively
 Palliative care emergencies – diagnosis and management
 Role of palliative care team in malignant and non-malignant diseases
 Role of palliative care team in hospital, hospice, home care and day hospice settings
 Role of multidisciplinary team
 Role of Advanced Nurse Practioner (ANP)
Technical Skills/Procedures
 General History and Physical Examination of all systems
 Assess for signs of spinal cord compression and superior vena caval obstruction &
management
 Assess patient for delirium and its management
 Recognise signs of opiod toxicity and its management
 Knowledge of common symptoms in the last 48 hours of life
 Familiar with drugs commonly used in Palliative Medicine
 Write an MDA prescription
 Introduction to medical ethics
 Understanding of psychosocial factors contributing to symptoms
 Recognise importance of spiritual care
 Understand the importance of family meetings
 Understand the importance of good communication skills
 Team working skills
Management and Professional Behaviour
 Full time attendance – will be given a detailed timetable of tutorials during 2 week
attachment
 Attendance at Journal Club Friday mornings at 8am
 Courtesy in dealing with patients, families and members of staff
 Empathise with patients
 Important to check with staff on ward as to the appropriateness of history taking
and/or examination of patients so as not to intrude on patients or families
unnecessarily
At the end of this attachment the assessment format will include some of the following
 Review student log to ensure goals have been met
 Powerpoint presentation on last day of attachment
31 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE :
Physical and Rehabilitation Medicine.
Dr. Jacinta McElligott
AMiNCH, Peamount, NRH
3
Objectives:
-
-
Understand the World Health Organization concepts of Impairment, Activity and
Participation.
Use case studies to link the clinical assessment and examination of a patient with
neurological impairments with anticipated functional deficits.
Understand the holistic approach and role of the multidisciplinary rehabilitation
team in improving rehabilitation specific outcomes in patients with severe
impairments associated with neurological disorders.
Students must exhibit attitudes of empathy accompanied by a satisfactory comfort
level with patients with chronic acute and chronic illnesses and disabilities.
World Health Organization.
Body functions are the physiological functions of body systems, including psychological
function.
-
Impairments are abnormalities of function or structure
o the physiological dysfunction = impairment.
-
Activity is the execution of a task or action by an individual and represents the
individual perspective of functioning i.e. the ability to perform basic personal care
needs.
o Activity limitations = disability.
-
Participation refers to the involvement of an individual in a life situation and
represents the societal perspective of functioning.
o Participation limitations = handicap or inability to engage in normal societal
role.
Rehabilitation.
Rehabilitation is an active process by which those disabled by injury or disease achieve full
recovery, or, if full recovery is not possible, realize their optimal physical mental and social
potential and are integrated into their most appropriate environment.
Physical Medicine: Interventions aimed at improving physiological and mental functioning.
Rehabilitation Medicine: Enabling people to participate actively in society.
See Appendix 1 for specialised proformas.
32 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Respiratory
Professor Lane, Dr Moloney
AMiNCH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to:
Know
- Normal physiology of the respiratory system including mechanics of breathing,
oxygen delivery, lung volumes, capacities and normal blood gasses and anatomy of
bronchial tree/lungs..
- Recognise signs and symptoms of upper and lower respiratory tract diseases.
- The range of tests available and indications for use including pulmonary function
and brochoscopy.
- Understand in detail the common pulmonary diseases such as; asthma, chronic
obstructive airways disease, pneumonia, TB, sleep apnoea, and disorders of
ventilation and lung cancer.
- Basic knowledge of the principles of inhaler therapy, oxygen therapy, non-invasive
ventilation and pulmonary rehabilitation.
Technical Skills/Procedures
Be able to:- Take comprehensive medical history, including detailed occupational history.
- Do a full physical examination of resting respiratory rate and depth, presence or
absence of tachypnoea or cyanosis, chest configuration and movement, finger
clubbing, location of the trachea, auscultation of breath sounds and any additional
sounds such as crackles and wheezes. Percussion of lungs, liver and cardiac borders.
- Be familiar with techniques and principles of laboratory testing of pulmonary
function.
- Interpretation of basic chest x-rays.
- Observe and describe the procedure of bronchoscopy.
- Manage foreign body inhalation (Heimlich Manoeuvre)
Management and Professional Behaviour.
The student always be:
- Well dressed and punctual.
- Alert to patient needs and sensitivities.
- Ready to show empathy combined with firm patient management skills.
- Able to establish a good working relationship with team members and peers.
- Resourceful and flexible in the work situation. Willing to accept responsibility for
his/her own learning and read outside the box.
At the end of this attachment the assessment format will include:
 Interpretation of Chest x-ray, basic only.
 How to approach interpreting a chest x-ray, (not necessarily recognising abnormal
CXR).
 Interpretation of abnormal pulmonary function laboratory results.
 What is meant by FEV, FVC, Lung volumes, diffusion
 Interpretation of abnormal blood gases, understand acid-base abnormalities.
 Presentation of a case of lung cancer, asthma and COPD.
 Discussion of drug therapy options in asthma and COPD.
33 | Clinical Attachments
Speciality:
Consultants:
Hospital:
Year of Course:
Respiratory
Prof. Stephen Lane; Dr. Eddie Moloney
Peamount
3
OBJECTIVES OF ATTACHMENT:
During this attachment a student is expected to know:

History
o Importance of symptoms
 Elucidate the prime symptom
 Associated symptoms
o 6 cardinal symptoms; hundreds of diseases
o Importance of time

Examination
o The 3 respiratory clinical areas
o Elimination of redundancy
o Localising v. non-localising
o Wheezes & Crackles

How to present a case
o Problem lists
o Main issue
o Mode of admission
o Blood flow charts
o Microbiology flow charts

Understanding the pathophysiology of respiratory failure
o Interpretation of arterial & venous blood gases
o PaO:FiO2 ratio
o Arterial-alveolar oxygen difference
o Hypoxaemic respiratory failure (Type1)
o Alveolar hypoventilation (Type 2)

Chronic disease management
o COPD
 Long term v. acute endpoints of disease
 AIR Programme
 Pulmonary rehabilitation
 COPD outreach
 HiTH
 BTS intermediate care guidelines
o Bronchiectasis
 ‘Biofilm reduction therapy’
 Pseudomonas positive v. negative
 Flutter devices
 Nebulised antibiotics
 Rotational antibiotics
34 | Clinical Attachments
o Asthma
 Exacerbation reduction
 Peak flow
 High dose steropis
 s.c. terbutaline
o Sleep
o Disorders of ventilation
o Pulmonary hypertension
 Classification
 Cor pulmonale
 Mechanism of fluid retention
 Therapeutics

Role of oxygen therapy in chronic respiratory disease
o LTOT
o Symptomatic portable

Practical skills
o Inhaler technique
o Setting up a nebuliser
o Setting up oxygen
 Relationship of flow rates to FiO2
 Prong v. masks
 Flow v. Venturi
 Non-rebreathing bags
o Setting up CPAP
o Setting up BiPAP
o Interpretation of peak flow diary card
o Mantoux test
o Skin allergy tests

Pulmonary function
o Working knowledge of routine spirometry, lung volumes and gas transfer
o Some knowledge of specialised tests
 Airway challenges
 Cardiopulmonary exercise tests
 Oximetry & capnography
 Sleep studies

Radiology
o How to read a chest x-ray
o How to read a CT scan
35 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Respiratory
Dr. F. O’Connell, Dr R. Fahy, Dr J. Keane
SJH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Knowledge
-
Basic respiratory anatomy (learn through CXR/Bronchoscopy)
Basic respiratory Physiology (learn through Pulmonary function)
Important features of the respiratory history
Clinical presentation and management of the common respiratory conditions
o Asthma
o COPD
o Respiratory failure
o Respiratory infections including TB
o Lung Cancer
Technical Skills/Procedures
- Detailed Respiratory History Taking
- Detailed Respiratory Examination
- Basic Chest X-Ray interpretation
- Performance and interpretation of spirometry
- Performance and interpretation of ABG’s
- Observation of bronchoscopy
Management and Professional Behaviour
- Full time attendance as part of the team
- Individual assessment of 2 patients per week from admission to discharge
- Courtesy in dealing with patients/staff
At the end of this attachment the assessment format will include
 Review student log of respiratory firm activities
36 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Rheumatology
Prof D. Kane
AMiNCH
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to:Know
- Demonstrate understanding of basic peripheral and spinal joint anatomy
- Understand the difference between inflammatory and non-inflammatory arthritis
- Develop a basic understanding of connective tissue diseases
- Interpret commonly requested laboratory tests
o inflammatory markers
o serology results/autoantibodies
- Clinical presentation and management of common rheumatic conditions
- Understand the roles of the members of the multi-disciplinary team
- Obtain further knowledge of general internal medicine
Technical Skills/Procedures
-
Learn to perform a screening musculoskeletal history and examination as part of
routine medical clerking (GALS)
Musculoskeletal history taking
} Learn about
Physical examination of the musculoskeletal system
} REMS
Interpretation of x-rays of joints: normal vs abnormal
o identification of changes of osteoarthritis, rheumatoid arthritis
Observation of joint aspiration and injection
Attend one session of outpatient physiotherapy and occupational therapy to
understand the roles of these disciplines in managing musculoskeletal disease
Management and Professional Behaviour
- Full time attendance as part of the rheumatology team
- Individual assessment of 2 or more in-patients per week, following patients through
their hospital course to discharge
- Courtesy in dealing with patients and members of staff
At the end of this attachment the assessment format will include
 Review student log to ensure goals have been met
37 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
YEAR OF COURSE
Rheumatology
Dr. Doran, Dr. Cunnane
St James’s Hospital
3
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
- Basic joint anatomy
- Understanding the difference between inflammatory and non-inflammatory arthritis
- Basic understanding of connective tissue diseases
- Interpreting commonly requested laboratory tests
o inflammatory markers
o serology results/autoantibodies
- Clinical presentation and management of common rheumatic conditions
- Further knowledge of general medicine
Technical Skills/Procedures
-
Musculoskeletal history taking
Physical examination of the musculoskeletal system
Interpretation of x-rays of joints: normal vs abnormal
o identification of changes of osteoarthritis, rheumatoid arthritis
Observation of joint aspiration and injection
Management and Professional Behaviour
-
Full time attendance as part of the rheumatology team
Individual assessment of 1-2 in-patients per week, following patients through their
hospital course to discharge
Courtesy in dealing with patients and members of staff
At the end of this attachment the assessment format will include
 Review student log to ensure goals have been met
38 | Clinical Attachments
Department of Medicine
Staff/Contact Numbers
St.James’s Hospital
Professor Dermot Kelleher
Chair of Medicine
Dr. Dermot O Toole
Senior Lecturer/Consultant
dermot.otoole@tcd.ie
Dr. Nasir Mahmud
Senior Lecturer/Consultant
nmahmud@tcd.ie
Dr. Michael Fay
Lecturer
michaelgfay@gmail.com
Dr. A Zaheer
Lecturer
zaheerab@tcd.ie
Dr. Murat Kirca
Lecturer
kircam@tcd.ie
Ms Clare Martin
Clinical Skills Tutor
martinc4@tcd.ie
Ms Triona Flavin
Clinical Skills Tutor
tflavin@tcd.ie
Ms Jacqueline O’Kelly
Executive Officer
01 8962101
okellyja@tcd.ie
AMiNCH
Professor Colm O Morain
Dean of Medicine
Dr Deidre McNamara
Senior Lecturer/ Consultant
mcnamad@tcd.ie
Dr Ronan Leen
Clinical Lecturer
Dr Chun Seng Lee
Clinical Lecturer
Ms Phillippa Marks
Clinical Skills Tutor
leenr@tcd.ie
Bleep 7128
leecs@tcd.ie
Bleep 7062
01 8961475
Ms Marie Morris
Clinical Skills Co-ordinator
& Tutor
Executive Officer
Ms. Amanda Lomax
39 | Clinical Attachments
01 8962910
01 8963844
Amanda.lomax@tcd.ie
Clinical Surgery
Introduction to the 41
Department of Surgery
Ward Guide 43
Breast 44
Including general
Surgery
Cardiothoracic 46
Colorectal 48
Including general Surgery
General Surgery 49
Plastic and 51
Reconstructive Surgery
Trauma and Orthopaedics 54
Upper GI 61
Including general Surgery
Urology 64
Vascular
70
Useful Contacts 74
Although the placements are listed for St James’ Hospital, the teams
in AMiNCH and Naas have a very similar patient base, and so the
objectives apply to any site. The Consultants for AMiNCH & Naas
are listed in the Ward Guide.
40 | Clinical Attachments
Introduction to the Department of Surgery
Welcome to the clinical side of learning that you have all been looking forward to. The
following details will give you an overview of the 3rd Year surgical rotation programme.
Here is a guide to which ward your team is attached to, followed by questions to prompt
your learning based on your attachment.
During your clinical attachment you are assigned to clinical teams and are expected to
integrate fully and become involved in all activities of the clinical team. The standard day is
from 7/7.30 am until clinical activities end for the day. You should attend all theatre
sessions, outpatient clinics and endoscopy sessions with members of the team, unless
engaged in other formal learning activities. You should be prepared to present cases on
ward rounds, particularly consultant led ward rounds.
You should follow a number of patients in more detail during clinical attachment – this
includes taking a full history and examination. This should be supplemented this with
reading about their medical and surgical problems. You should present this case to at least
one member of the team and request their feedback on their performance. Students should
be aware of their patient’s active problems, vitals, fluid balance, laboratory investigation
results and procedures to be done.
We suggest that students identify a number of disease processes or conditions with which
they would like to become familiar with during their clinical attachment. These conditions
may depend on the types of patients which are routinely cared for by the team to which you
are attached (e.g. patients with oesophageal cancer, acute appendicitis, colorectal cancer,
pancreatitis and so forth) or they may come from another speciality to which are not
currently attached. The aim is so see as many patients as possible and to supplement what
you experience with reading about the relevant disease process. I
Rationale and aims
The principles of surgical practice module is a mandatory component of the sophister (3rd
medical year) course.
It is envisaged that students will gain a sound understanding of the principles of surgery and
the common surgical presentations during the third medical year. Communication and
presentation skills are critical to producing good physicians. With a good working
knowledge of the fundamentals of surgery, you can then move on to hone clinical skills and
acquire further in-depth knowledge in their final year.
Learning objectives:





Basic science in the practice of surgery
Surgical knowledge
Basic clinical skills
Interpersonal and communication skills
Ethical judgement and professionalism
41 | Clinical Attachments
Learning outcomes
On successful completion of this course, students will be able to
1) Explain the fundamental principles underlying the pathophysiology and presentation of
common surgical conditions
2) Make accurate observations of clinical phenomena and appropriate critical analysis of
clinical data in order to justify the selection of appropriate investigations for common
clinical cases
3) Elicit a patient’s concerns and understanding of their condition and treatment options and
their views, values and preferences
4) Make an initial assessment of a patient’s problems and a differential diagnosis by
understand the processes by which doctors make and test a differential diagnosis and
proceed to synthesise all the available information to make clinical judgements and
decisions, within the scope of their competence.
5) Assess and recognise the severity of a clinical presentation and a need for immediate
emergency care
6) Critically appraise the results of relevant diagnostic, prognostic and treatment trials and
other qualitative and quantitative studies as reported in the medical and scientific literature.
7) Recognise the attitudes and professional and ethical standards which underpin current
surgical practice including those of patient autonomy, informed consent, safe operating
practice
8) Establish and maintain good relationships with colleagues by effective and sensitive
communication through comprehension of the contribution that effective interdisciplinary
teamworking makes to the delivery of safe and high quality care.
A list of specific learning objectives for the third medical year has been published on the
departmental website (http://www.tcd.ie/surgery) and in appendix 3.
42 | Clinical Attachments
Department of Clinical Surgery- St James Hospital
Speciality
Ward
Consultants
Upper GI
Colorectal
Breast and Endocrine
Vascular
Urology
(G.U. Surgery)
Plastics
Bennett’s Ward
Dun’s Ward
Bennett’s Ward
Dun’s Ward
Bennett’s Ward
Professor Reynolds, Mr N. Ravi
Mr. Stephens, Mr Mehigan
Mr Boyle, Ms. Connolly, Mr J Butt
Mr. Moore, Mr. Madhavan, Mr. O’Neill,
Mr McDermott, Mr. Lynch, Mr. Grainger
Ann Young Ward
Cardiothoracic
Orthopaedics
Keith Shaw Ward
Colle’s Ward
ENT
John’s Ward
Mr. Orr, Ms. Eadie, Mr. Beausang, Mr.
O’Donavan, Mr. Meagher, Mr Murray
Ms. McGovern, Mr. Young, Mr. Tolan
Mr. Hogan, Mr. Smyth, Mr. McCarthy, Mr.
McKenna
Professor Timon, Mr. Conlon, Mr. McShane, Mr.
Kinsella, Mr Rafferty
Department of Clinical Surgery- AMiNCH
Speciality
Upper GI/HPB and
General Surgery
Colorectal Surgery
Vascular Surgery
G.U. Surgery
Ward
Crampton Ward
Gogarty Ward
Lynn Ward
Crampton Ward
Gogarty Ward
Maguire Ward
Crampton Ward
Gogarty Ward
Lane Ward
Trauma Orthopaedic
Surgery
Franks Ward
Elective Orthopaedic
Surgery
Ormsby Ward
Consultants
Prof. KCP Conlon,
Mr. Paul F. Ridgway,
Mr Asem Hamdy
Mr. Paul Neary, Mr. Diarmuid O’Riordain
Mr. Emmanuel Eguare
Mr. Martin Feeley, Prof. Sean Tierney,
Ms Bridget Egan
Mr. Ronald Grainger, Mr. Robert Flynn,
Mr. TED McDermott, Mr. John Thornhill,
Mr. Thomas Lynch
Mr. John McElwain, Mr. Paul Nicholson,
Mr Maurice Nelligan, Mr Seamus Morris,
Ms Paula Kelly
Mr. John McElwain, Mr. Paul Nicholson,
Mr Maurice Nelligan, Mr Seamus Morris
Ms Paula Kelly
Department of Clinical Surgery (Naas)
Speciality
Colorectal Surgery
General / Breast Surgery
General Surgery
43 | Clinical Attachments
Ward
Allen Ward
Allen Ward
Allen Ward
Consultants
Mr. Diarmuid O’Riordain
Ms. Jane Rothwell
Mr. F. Laabei
SPECIALTY:
CONSULTANT:
HOSPITAL:
Breast surgery (& General Surgery)
Mr Boyle, Ms Connolly, Mr Butt
SJH
OBJECTIVES OF ATTACHMENT: (Please also see general surgery objectives)
Have an understanding of
-
Benign breast disease
Assessment and management of a breast lump
Malignant breast disease
Understanding of surgical management of breast cancer
Adjuvant therapies for breast cancer
Familial breast disease
Students should have knowledge of the clinical presentation, investigations and
management of the following scenarios
-
Patient with breast lump
Patient with breast pain
Patient with strong family history of breast cancer
Patient post mastectomy/WLE/axillary clearance
Examination Skills
-
Be able to perform a full breast examination
Theoretical knowledge of normal and abnormal findings on breast exam
Be able to examine the axilla
Scenario Based Learning Objectives.
Patient with breast pain
-
Outline the common causes of breast pain
Outline the first line investigations if necessary of a patient with breast pain
Outline the second line investigations based on the common first line findings
Patient with nipple discharge
-
Outline the common causes of nipple discharge
Outline the first line investigations if necessary of a patient with nipple discharge
Outline the second line investigations based on the common first line findings
Young patient with breast lump
-
Examine the breast lump and assess
Outline basic first line investigations
Say how you would assess the need for intervention
Describe the most common differential diagnoses for a young woman with a breast
lump
44 | Clinical Attachments
Older patient with breast lump
-
Examine the breast lump, axilla and assess
Outline basic first line investigations
Outline the second line investigations based on the common first line findings
Say how you would assess the need for intervention
Describe the most common differential diagnoses for an older woman with a breast
lump
Describe the common surgical options for the patient
All students should have seen during their rotation the following:
-
Triple assessment of a breast lump including US/mammogram, FNA/core biopsy
Mastectomy
Wide local excision
Sentinel node biopsy
Axillary clearance
All students by the end of the rotation should be able to describe the mechanism of
action and role of the following drugs used in Breast Surgery;
-
Tamoxifen
Her2 receptor blockers
Aromatase inhibitors
All students by the end of final medical years should have developed the following
skills:-
The ability to take a full history on breast problems
The ability to perform a full breast and axillary exam
The ability to manage a breast symptom with appropriate investigations
The ability to describe the surgical options for a patient with breast cancer
The ability to describe sentinel node biopsy
The ability to briefly describe adjuvant therapies for breast cancer
Management and Professional Behaviour
- Full attendance at weekly schedule and Ward round each morning at 7.30am
Bennett’s ward
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
45 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
Cardiothoracic surgery
Ms. McGovern, Mr. Young, Mr. Tolan
SJH
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
-
-
The Heart
o Indications for aortic and mitral valve replacement
o Types of prosthetic heart valves
o Risk factors for coronary artery disease
o Indications and methods of surgery in coronary artery disease
o The role of the heart-lung machine in cardiac surgery
o Indications and methods for temporary and permanent cardiac pacing
o Methods to augment cardiac output by manipulating preload, afterload and
cardiac function.
The Lung
o Different types of lung cancer
o Evaluation of a patient with lung cancer for operability and resectability
o Workup of a patient with a lung nodule
o Evaluation of a pleural effusion
o Indications for insertion of chest drains
o Presentation and management of a pneumothrax
The student should be familiar with the diagnostic procedures used to evaluate the heart and
lungs. Specifically:

Angiograms, Pulmonary artery catheters, Bronchoscopy, CT scans of the chest,
pulmonary function tests and ventilation perfusion scans. PET scans.
Technical Skills/Procedures
-
The student should be able to take relevant history
The student should be able to interpret heart murmurs and respiratory sounds
The student should understand how a bypass machine works and how a chest
tube works
All students should have seen during their rotation the following:
Bypass machine
Central line
CABG
Lung resection
Trans-oesophageal and Trans-thoracic echo
Diagnostic angiogram
46 | Clinical Attachments
Chest drain
Valve replacement
Saphenous vein harvesting
Bronchoscopy
Management and Professional Behaviour
- Full attendance at weekly schedule
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
47 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
Colorectal surgery (& General Surgery)
Mr. Paul Neary, Mr. Diarmuid O’Riordain
Mr. Emmanuel Eguare
AMNCH
OBJECTIVES OF ATTACHMENT (Please also see general surgery objectives)
During this attachment a student is expected to know
-
-
Pathophysiology of colorectal cancer
Colorectal cancer, diagnosis and management including operative and non-operative
treatment
Staging systems for colon and rectal cancer
Modalities for management of colorectal cancer, their indications and outcomes
(survival, morbidity).
To understand the different staging modalities employed (Endorectal, PET-CT etc)
and how this information is synthesised in order to plan treatment
The use of minimally invasive therapy in managing colorectal disease.
Appreciate the importance of multidisciplinary approach to cancer therapy and the
role surgical specialists play on that team
Pathophysiology of inflammatory bowel disease, ulcerative colitis and Crohn’s
disease, diagnosis and surgical management including management of their
emergencies.
Management of acute diveriticulitis and its complications.
Diagnosis and management of benign anorectal condition
Specific Knowledge: The student will be expected to demonstrate a fundamental
knowledge and understanding of the following areas and disease processes.
Appendicitis, Normal & Disorders of colonic physiology, Intestinal obstruction,
Pseudo-obstruction, Volvulus, Diverticular Disease, Lower GI Haemorrhage,
Colitis, Inflammatory Bowel disease, Haemorrhoids, Pilonidal Sinus, Perianal
Abscess, Perianal Fistulae, Incontinence, Anal Fissure, Colorectal Carcinoma,
Small-bowel Obstruction. Infectious diseases of the Small Bowel, Meckel’s
Diverticulum, Small bowel Neoplasms, Disturbances of small-bowel physiology,
Crohn’s Disease, Mesenteric Ischaemia
Technical Skills/Procedures
The student will be able to do the following to the satisfaction of his/her supervisor(s):
-
Take full relevant history
Do a comprehensive physical examination
Arrive at an appropriate differential diagnosis.
Order appropriate laboratory, radiological and other diagnostic procedures and
demonstration of knowledge in the interpretation of these investigations.
Acceptable plan of management and demonstration of knowledge of the
Appropriate operative and non-operative management of the disease process
48 | Clinical Attachments
Management and Professional Behaviour
- Full attendance at weekly schedule
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
- Attendance at theatre
At the end of this attachment the assessment format will include
 Review student log book
 Feedback on level of integration with the team and patients
 Formal assessment as per medical school
 Presentation of cases
49 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
Colorectal surgery (& General Surgery)
Mr Mehigan, Mr McCormick
SJH
OBJECTIVES OF ATTACHMENT (Please also see general surgery objectives)
During this attachment a student is expected to
Know
- Understand the pathophysiology of inflammatory bowel disease
- Distinguish between ulcerative colitis and Crohn’s disease
- Recognise indications for surgical management in IBD
- Demonstrate an understanding of the differences between emergency surgery for
acute flares in IBD and elective procedures
- Comprehend the challenges associated with surgery in acutely unwell patients e.g.
acute diveriticulitis, acute ulcerative colitis etc. with respect to complications,
nutrition etc.
- To become familiar with the pathophysiology of colorectal cancer and the specific
physiologic responses of cancer patients to operative and non-operative treatment.
- To understand the staging systems for colon and rectal cancer
- To distinguish between the different staging modalities employed (EUS, PET-CT
etc) and how this information is synthesised in order to plan treatment
- To know the different treatment modalities for colorectal cancer, their indications
and their outcomes (survival, morbidity etc.)
- To begin to appreciate the multidisciplinary approach to cancer therapy and the role
surgical specialists play on that team
Technical Skills/Procedures
The student will be able to do the following to the satisfaction of his/her supervisor(s):
-
Take a relevant history.
Perform an acceptable physical exam concentrating on the relevant areas.
Arrive at an appropriate differential diagnosis.
Order appropriate laboratory, radiological and other diagnostic procedures and
demonstration of knowledge in the interpretation of these investigations.
Arrive at an acceptable plan of management and demonstration of knowledge of the
appropriate operative and non-operative management of the disease process.
Management and Professional Behaviour
- Full attendance at weekly schedule & Ward round each morning at 7.30am Sir
Patrick Dun’s ward
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include
 Review student log book
 Feedback on level of integration with the team and patients
 Formal assessment as per medical school
 Presentation of cases
50 | Clinical Attachments
SPECIALTY:
CONSULTANT:
General surgery
All consultants practising general surgery
Upper GI Professor Reynolds, Mr Ravi
Colorectal Mr Mehigan, Mr McCormick
Breast and Endocrine Mr Boyle, Ms. Connolly, Mr Butt
HOSPITAL:
SJH
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
-
-
-
-
-
-
To become familiar with the recognition, natural history, and general and specific
treatment of those adult general surgical conditions that one would expect to
encounter in a general surgery practice in a community.
To familiarise oneself with the pathophysiology of common general surgical
conditions.
To become familiar with the recognition and natural evolution of those surgical
oncology conditions that he/she would be expected to encounter in a general surgical
practice in a community lacking the immediate availability of a surgical oncologist.
To become familiar with the pathophysiology of various surgical oncology
conditions and the specific physiologic responses of cancer patients to operative and
non-operative treatment.
To become familiar with the pathophysiology of various surgical oncology
conditions and the specific physiologic responses of cancer patients to operative and
non-operative treatment.
To particularly understand the following oncologic diseases: breast cancer,
colorectal cancer, melanoma, sarcoma, thyroid cancers, pancreatic cancer, liver
cancers, lung cancer, stomach cancer, bile duct tumours, oesophageal cancer.
To begin to appreciate the multidisciplinary approach to cancer therapy and the role
surgical specialists play on that team
Specific Knowledge
The student will be expected to demonstrate a fundamental knowledge and understanding of
the following general areas and disease processes.
-
Hernias-inguinal, umbilical, epigastric, ventral.
Management of Gallbladder disease
Management of thyroid and parathyroid disorders
The approach to a patient with gastrointestinal bleeding
Management and surgical options in gastroesophageal reflux disease and peptic
ulcers
The approach to a patient with inflammatory bowel disease
The approach to a patient with pancreatitis
Fluid and dietary management of the surgical patient Indications for and
complications of central venous lines in children
Anal fissures, perirectal absess and fissure-in-ano
The "Acute Abdomen"-acute appendicitis, perforated viscus, acute gastroenteritis,
bowel obstruction.
51 | Clinical Attachments
Technical Skills/Procedures
Given a patient with a general surgical disease, the student will be able to do the following
to the satisfaction of his/her supervisor(s).
-
Take a relevant history.
Perform an acceptable physical exam concentrating on the relevant areas.
Arrive at an appropriate differential diagnosis.
Order appropriate laboratory, radiological and other diagnostic procedures and
demonstration of knowledge in the interpretation of these investigations.
Arrive at an acceptable plan of management and demonstration of knowledge of the
appropriate operative and non-operative management of the disease process.
Management and Professional Behaviour
- Full attendance at weekly schedule
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
52 | Clinical Attachments
SPECIALTY:
CONSULTANT:
Plastics and reconstructive surgery
HOSPITAL:
SJH
Mr. Orr, Ms. Eadie, Mr. Beausang, Mr. O’Donavan, Mr. Meagher,
Mr Murray
OBJECTIVES OF ATTACHMENT
Have an understanding of the following
-
Hand injuries
Skin lesions – benign and malignant
Burns
Skin grafts
Wound healing and the reconstructive ladder
Students should have knowledge of the clinical presentation, investigations and
management of the following scenarios:
-
Patient with burns – superficial and deep
Patient with skin lesions – benign and malignant
Patient with traumatic hand injury – nerve/tendon/vessel
Patient with Dupuytrens contracture
Patient post-mastectomy/for breast reconstruction
Patients requiring skin grafts or flaps for defects
Examination Skills:
-
Be able to perform a full hand examination – tendons and nerves
Be able to assess a burn in terms of percentage and thickness
Be able to describe and diagnose common skin lesions especially skin cancers
Be able to describe a skin graft and assess
Be able to describe a wound and assess in terms of type and degree of healing
Be able to recognise common free flaps eg forearm, ALT and common pedicled
flaps eg TRAM, latissimus dorsi
Scenario Specific Learning Objectives
Patient with burns
-
Assess the patient in terms of basic trauma ie airway/breathing/circulation
Assess the area of burn and draw onto Lund and Browder chart
Assess depth of burns
Recognise infection in burn site
Be able to manage burn in terms of fluid resuscitation and basic support
Describe further management ie debridement and skin grafting if necessary
Assess if patient needs to be transferred to burns unit
Patient with skin lesion
-
Describe the lesion and diagnose
Describe what management would be appropriate for the lesion
53 | Clinical Attachments
-
Describe basic surgical technique for excision and methods for wound closure
Describe the reconstructive ladder for wound healing in plastic surgery
A patient with hand injury
-
Examine the hand in terms of flexor and extensor tendon injury
Examine the hand in terms of nerve or vessel injury
Discuss the diagnosis and surgical management of the injury
Briefly discuss the functional implications of the injury for the patient
Describe common complications of the surgery
Patient with Dupuytrens contracture
-
Describe the deformity and functionally assess patient
Discuss the presentation, diagnosis and management options for Dupuytrens
contracture
Briefly describe the surgery for Dupuytrens contracture
A patient with a skin defect requiring reconstruction
-
Describe the defect which will be left
Discuss the reconstructive ladder and what options are appropriate for the defect in
question
Describe the differences between types of skin grafts
Describe the differences between types of flaps and know common free and pedicled
flaps
Discuss the common complications of skin graft and flap reconstruction
Patient requiring breast reconstruction
-
Discuss the different options for breast reconstruction
Briefly discuss the benefits of different types of reconstruction
Discuss complications of breast reconstruction
All students should have seen during their rotation the following:
Flexor tendon injury in hand
Nerve injury in hand
BCC, SCC, malignant melanoma
Partial and full thickness burns
Breast reconstructions
Local flap reconstructions
Dupuytrens contracture
Benign skin lesions
Split skin grafts and full thickness skin grafts
Pedicled and free flap reconstructions
All students by the end of final medical years should have developed the following
skills:-
The ability to assess a burn and to manage the burn in terms of basic resuscitation
The ability to assess and diagnose a skin lesion
The ability to describe the reconstructive ladder and types of wound healing
The ability to assess a skin graft
The ability to examine the hand and describe tendon/nerve/vessel injuries
54 | Clinical Attachments
Management and Professional Behaviour
- Full attendance at weekly schedule, Ward round each morning at 7.30am Anne
Young ward
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
55 | Clinical Attachments
SPECIALTY:
CONSULTANT:
Trauma and Elective orthopaedics
HOSPITAL:
AMNCH
Mr. John McElwain, Mr. Paul Nicholson,
Mr Maurice Nelligan, Mr Seamus Morris,
Ms Paula Kelly
OBJECTIVES OF ATTACHMENT
Trauma:
Aims
o
o
o
o
o
o
o
o
o
o
o
o
o
To take a focused and relevant history for Trauma and Orthopaedic patients
Perform a through physical examination of the musculoskeletal system.
Formulate a reasonable diagnosis based on clinical findings
To obtain sufficient knowledge of the common Orthopaedic and trauma
conditions including the aetiology, pathology and their clinical features.
To arrive at a provisional diagnosis based on the signs and symptoms elicited and
the knowledge acquired
Select the relevant investigations, justifying why they are necessary, and interpreting
the results
Formulate a plan of management and discuss the rationale
Recognise the possible complications the condition and also the treatment
Understand the importance of physiotherapy, occupational therapy and rehabilitation
Understand the mechanics of commonly used prostheses and orthoses
Acquire the basic skills of application of plaster casts and traction apparatus
Basic understanding of classification of the different fractures
Specific Knowledge:
The student will be expected to demonstrate a fundamental knowledge and understanding of
the following areas and disease processes
Fractures and Joint Injuries:
Fractured clavicle, Dislocation of the shoulder, Fractured shaft of humerus, Supracondylar
fracture, Fracture olecranon, Dislocation of the elbow, Fractures of the radius and ulna,
Fractures distal end of Radius, Scaphoid fractures, Metacarpals and phalanges fractures,
Diagnosis and principles of acute management of spine injuries, Traumatic paraplegia and
spinal cord injury rehabilitation, Complications of unstable fractures of the pelvis, Femoral
neck and intertrochanteric fractures of the pelvis, Femoral shaft fractures, Fracture patella,
Dislocation of the knee/internal derangement of the knee, Fractures tibia and fibula,
Fractures around and ankle/foot
Orthopaedic disorders
Acute haematogenous osteomyelitis, Chronic osteomyelitis, Acute suppurative arthritis,
Tuberculous arthritis, Rheumatoid arthritis, Gouty arthritis, Osteoarthritis, Seronegative
arthritis, Avascular necrosis of the femoral neck, Osteoporosis, Osteosarcoma,
Osteochondroma, Giant cell tumor, Multiple myeloma, Ewing sarcoma, Metastatic tumours
in bone, Orthopaedic problems in cerebral palsy, Peripheral nerve lesions, Amputations,
Rotator cuff problems, Cubitus varus, Tennis elbow, Ganglion, De Quervain’s disease,
Carpal tunnel syndrome, Trigger finger, Acute infections of the hand, Low backache and
neck pain, Dysplastic Dysplasia of the hip, Perthes’ disease, Slipped upper femoral
epiphysis, Genu varum and genu valgum, Popliteal cyst, Congenital talipes equinovarus,
Ruptured tendo Achillis, The diabetic foot, Ingrown toenail, Heel pain
56 | Clinical Attachments
Management and Professional Behaviour
- Full attendance at weekly schedule,
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
- Attendance in theatre
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
57 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
Trauma and orthopaedics
Mr. Hogan, Mr. Smyth, Mr. McCarthy, Mr. McKenna
SJH
OBJECTIVES OF ATTACHMENT
Trauma:
Aims
-
-
To become familiar with the recognition, natural history, and general and specific
treatment of those trauma conditions that one would expect to encounter in a general
surgery practice in a community.
To familiarise oneself with the pathophysiology of trauma, and the response of a
patient to injury.
More specifically awareness of the following topics is recommended:
- Type of road traffic accident such as Vehicle/fall/mass injury.
- Importance of acceleration and deceleration impacts. Driver, passenger or
pedestrian.
- ABC of Advance trauma life support (ATLS) system.
- Significance of associated abdominal, chest and head injury.
- What is the Glasgow coma scale and its relevance with management of the patient.
- Solid organ versus hollow viscus injury, how do they present clinically.
- Soft tissue trauma and blood loss.
- Importance of fracture stabilisation with external splints.
- Concept of POP, CAST and backslabs and their risks such as compartment
syndromes.
- Benefits of internal fixation of long bone fractures. Such as early mobility and
reducing the risk of thrombo-embolism.
Clinical Objectives
-
-
-
Understand the importance of and reasons for the trauma admission check list.
Complete at least one history and physical examination form including collection of
all appropriate laboratory and radiological data.
Be able to list and discuss the four phases and principles of Advanced Trauma Life
Support, to include:
o Primary Survey (ABC's)
o Resuscitation
o Secondary Survey
o Definitive Care.
Be able to verbally present clinical cases concisely and accurately during daily
rounds.
Be able to write thorough, concise and appropriate daily progress notes.
Participate actively in the surgical outpatient specialty clinic: Understand the
pathophysiology and diagnostic work up of patients reviewed in the clinic.
Clinically:
-
Take a relevant history in the trauma bay
Perform an acceptable physical exam concentrating on the relevant areas.
Arrive at an appropriate differential diagnosis.
58 | Clinical Attachments
Technical Skills
-
-
Be able to perform all technical aspects related to performing a physical
examination, to include: Glasgow Coma Scale determination, auditory canal
examination, palpation, rectal and pelvic examinations, and thorough body
evaluation.
Be able to perform placement- of indwelling catheters, to include: naso and
orogastric tubes, Foley catheters, venipuncture, and arterial puncture.
Be able to close simple lacerations with staples, stitches or subcuticular closure.
Be able to care and treat wounds, indwelling catheters and drains.
Elective Orthopaedics
The student should be able to:
-
-
Develop an understanding and management plan for the common referrals to the
orthopaedic specialty clinic. These include neck, back, and hip and knee pain.
Master the critical perioperative management skills that cross-surgical specialties
(i.e., prevent/recognition of DVT/PE, fever work-up, fluid management, anesthetic
concerns).
Understand the principles of fracture management
Become familiar with basic orthopaedic terminology (i.e., varus/valgus, ROM
measurements, etc.)
Understand the principles of casting and cast management.
Knowledge of common fractures: presentation, including mechanical forces leading
to the deformity and the treatment options for common fractures.
List the causes of joint effusions/swelling and relate these to patient presentation
Describe the pathophysiology of osteoarthritis and indications for arthroplasty.
Suggest the appropriate treatment option for common orthopaedic conditions:
Treatments options include: Conservative management and immobilisation,
physiotherapy, minimally invasive techniques, joint fixations and replacements.
Clinical skills
1. Perform a musculoskeletal history and physical exam with the appropriate
evaluation of the neurovascular components.
2. Apply a backslab or cast under supervision
History
- Disability such as nature of pain, with its area of involvement. e.g, hip pain, knee
pain, neck pain and back pain.
- Duration of debility and its effect upon lifestyle.
- Physical deformity due to presenting complaint. such as limping, flexures and
kyphosis.
- Radiation of pain especially along the back of leg called sciatica.
- History of any arthropathy especially Rheumatoid Arthritis.
- Past history of trauma or intervention such as arthroscopy for diagnosis.
59 | Clinical Attachments
Physical examination
- Obvious limb shortening and fixed flexures.
- Valgus or varus deformity
- Kyphosis or Lordosis
- Joint effusion and how to elicit it.
- Range of movements of affected joints.
- Straight leg raising angles.
- Neurological examination as part of an overall assessment.
Investigations
- Blood tests and Radiology
- Special tests such as C/T, MRI, bone scans for individual cases
Management and Professional Behaviour
- Full attendance at weekly schedule, Ward round each morning at 7.30am Colles’
ward
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
60 | Clinical Attachments
SPECIALTY:
CONSULTANT:
Upper GI surgery (& General Surgery)
HOSPITAL:
AMNCH
Prof. KCP Conlon,
Mr. Paul F. Ridgway
Mr Asem Hamdy
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
-
-
Pathophysiology of oesophageal, gastric and pancreatic cancer and the specific
physiologic responses of cancer patients to operative and non-operative treatment.
Staging of oesophageal and gastric cancer
Different staging modalities employed (EUS, PET-CT etc) and their role in planning
treatment
Different treatment modalities for oesophageal and gastric cancer
Diagnosis and treatment of pancreatic cancer
To understand the impact of oesophagectomy, gasrerectomy and
pancreaticoduodenectomy on the patient’s general physical condition and thus
understand the importance of pre-operative patient selection and optimisation
The importance of multidisciplinary approach to cancer therapy and the role surgical
specialists play on that team
Pathophysiology of gastro-oesophageal reflux disease and its management.
Pathophysiology, diagnosis and management of pancreatitis
Specific Knowledge: The student will be expected to demonstrate a fundamental knowledge
and understanding of the following areas and disease processes.








Oesophageal disorders: Hiatus Hernia, GORD, Barrett’s Oesophagus , Oesophageal
Carcinoma, Oesophageal Diverticulae, Functional Disorders of the Oesophagus,
Oesophageal Strictures, Caustic Ingestion and Complications of Oesophageal
Surgery
Stomach Disorders, Peptic ulcer disease, Gastric Adenocarcinoma, Primary Gastri
Lymphoma, Benign Gastric Tumours, Postgastrectomy Syndromes and Upper GI
Haemorrhage
Cholelithiasis
Biliary Disorders: Acute Cholecystitis, Choledocholithiasis, Ascending Cholangitis,
Acalculous Cholecystitis, Sclerosing Cholangitis, Choledochal Cysts, Biliary Tree
Tumours, Carcinoma of the Gallbladder, Bile Duct Injuriesand principles of ERCP
Surgical liver disease: Primary and Secondary Liver Tumours, Hepatic Abscess
Hepatic Cyst and Portal Hypertension
Pancreatic disease: Acute Pancreatitis, Chronic Pancreatitis, Pancreatic Carcinoma
Congenital Pancreatic Abnormalities, Exocrine pancreatic insufficiency, Pancreatic
Cystic Disease and Neuroendocrine tumors of the pancreas.
Disorders of the spleen: Haematological Disorders, Cysts, tumours & abscesses and
Splenectomy.
61 | Clinical Attachments



Hernia: Inguinal Hernias, Femoral Hernias, Internal Hernias, Abdominal Wall
Hernias
Sarcoma management
Adrenal gland disorders : Adrenal Cortex Tumours, Adrenal Medulla Tumours,
Adrenocortical Carcinoma, Endocrine Tumours & Carcinoid and Metastaic adrenal
tumour
Technical Skills/Procedures
the student will be able to do the following to the satisfaction of his/her supervisor(s):
-
Take a relevant history.
Perform an acceptable physical exam concentrating on the relevant areas.
Arrive at an appropriate differential diagnosis.
Order appropriate laboratory, radiological and other diagnostic procedures and
demonstration of knowledge in the interpretation of these investigations.
Arrive at an acceptable plan of management and demonstration of knowledge of the
appropriate operative and non-operative management of the disease process.
Applying suturing technique in theatre
Management and Professional Behaviour
- Full attendance at weekly schedule
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
- Attendance in theatre
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
62 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
Upper GI surgery (& General Surgery)
Prof Reynolds, Mr Ravi
SJH
OBJECTIVES OF ATTACHMENT (Please also see general surgery objectives)
During this attachment a student is expected to
Know
-
-
-
To become familiar with the pathophysiology of oesophageal and gastric cancer and
the specific physiologic responses of cancer patients to operative and non-operative
treatment.
To understand the staging systems for oesophageal and gastric cancer
To distinguish between the different staging modalities employed (EUS, PET-CT
etc) and how this information is synthesised in order to plan treatment
To know the different treatment modalities for oesophageal and gastric cancer, their
indications and their outcomes (survival, morbidity etc.)
To understand the impact of oesophagectomy on the patient’s general physical
condition and thus understand the importance of pre-operative patient selection and
optimisation
To begin to appreciate the multidisciplinary approach to cancer therapy and the role
surgical specialists play on that team
Understand the pathophysiology of gastro-oesophageal reflux disease and the
approach to its management.
Technical Skills/Procedures
the student will be able to do the following to the satisfaction of his/her supervisor(s):
-
Take a relevant history.
Perform an acceptable physical exam concentrating on the relevant areas.
Arrive at an appropriate differential diagnosis.
Order appropriate laboratory, radiological and other diagnostic procedures and
demonstration of knowledge in the interpretation of these investigations.
Arrive at an acceptable plan of management and demonstration of knowledge of the
appropriate operative and non-operative management of the disease process.
Management and Professional Behaviour
- Full attendance at weekly schedule
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
63 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
Urology
Mr. Ronald Grainger, Mr. Robert Flynn,
Mr. Ted McDermott, Mr. John Thornhill,
Mr. Thomas Lynch
AMNCH
OBJECTIVES OF ATTACHMENT (Please refer to Urology SJH objectives)
Students must have an understanding of the following symptoms;
Stream (poor/intermittent/splayed), hesitancy, post micturition dribble, urinary retention,
nocturia, double voiding
-
Daytime frequency, dysuria, urgency, strangury
Incontinence (stress/urge/continuous), enuresis
Haematuria
Renal/ureteric colic
Knowledge of the clinical presentation, investigations and management of the
following scenarios:
-
Patient with haematuria (either frank or microscopic, either painful or painless)
Patient with scrotal swelling (acute and chronic)
Patient with poor urinary stream (voiding and bladder storage problems)
Patient with renal/ureteric colic
Patient with urinary tract infection
Patient with bladder cancer
Patient with prostatic carcinoma
Patient with renal carcinoma
Patient with testicular cancer
Examination Skills:
-
Be able to perform a full abdominal examination including;
Theoretical knowledge of normal and abnormal findings on rectal exam
Be able to Ballott kidneys
Be able to describe the difference on clinical examination between palpable kidneys,
liver, spleen
Be able to percuss a bladder to determine if it is full or not
Testis examination
Scenario Based Learning Objectives
Patient with haematuria
-
Outline the common causes of haematuria
Outline the first line investigations of a patient with haematuria
Outline the second line investigations based on the common first line findings
Discuss the presentation and management of haematuria in relation to trauma to the
kidney, ureter, bladder and urethra.
Describe the presentation and treatment of patient with infections in the GU tract
64 | Clinical Attachments
-
Describe the aetiology, presentation and management of renal calculi
Patient with poor urinary stream
-
Describe the presentation of bladder outlet obstruction, the common causes and the
relevant questions
Describe how you would decide if intervention is required
Say how you assess the need for intervention
Outline the common treatment modalities for the common causes
Describe the management of benign prostatic hyperplasia
Describe the management of urethral stricture
Describe the complications of TURP
A patient with acute scrotal pain
-
Provide a differential diagnosis of acute scrotal pain
Discuss the presentation, diagnosis and management of torsion of the testis
Describe the indications for exploration of the testis
Patient with renal/ureteric colic
-
Provide a differential diagnosis for acute flank/abdominal pain
Discuss the presentation, diagnosis and management options for renal/ureteric
calculi
Describe a management plan for the investigation of recurrent renal calculi +
complications
A patient with a GU malignancy
-
Describe the presentation and management of renal cell carcinoma,
Describe the presentation and management of transitional cell carcinoma of the
bladder
Describe the presentation and management of carcinoma of the prostrate
Describe to presentation and management of testicular carcinoma
Patient with scrotal swelling




Discuss the differential diagnosis of a testicular swelling
Describe how you would distinguish a scrotal swelling from a hernia
Describe the role of transillumination
Distinguish between an epididymal and testis swelling
A patient with a kidney (and pancreas) transplant





List the indications for kidney transplantation
Indicate how you would decide on the suitability of a donor for organ transplantation
Describe the usual anatomical positions for renal transplant in children and adults
Outline the criteria for establishing death for the purposes of organ donation.
Broadly list the medications used in immunosuppression for transplantation
65 | Clinical Attachments
All students should have seen during their rotation the following:
CAPD Tenchkoff dialysis catheter
Ileal Conduit
Percutaneous Nephrostomy tube
Testicular tumour/exploration
KUB
Three way urethral catheter + Irrigation
TURP
Arteriovenous dialysis fistula
Nephrectomy incision
Hydrocoele
IVP
Cystoscopy
Suprapubic catheter
All students by the end of the rotation should be able to describe the mechanism of
action and role of the following drugs used in Urology;
-
Alpha antagonists
LHRH analogues
Antiandrogens
Anticholinergics
Genitourinary antibiotics
All students by the end of final medical years should have developed the following
skills:-
The ability to pass a urinary catheter
The ability to assess the prostate on rectal examination
The ability to interpret an IVU, KUB, renal isotope scan, and CT
The ability to interpret renal function from blood and urinary electrolyte results
The ability to examine the abdomen and identify an abdominal mass
The ability to examine the scrotum and diagnose the cause of testicular swellings
Management and Professional Behaviour
- Full attendance at weekly schedule;
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
66 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
Urology
Mr McDermott, Mr lynch, Mr Grainger
SJH
OBJECTIVES OF ATTACHMENT
Students must have an understanding of the following symptoms;
Stream (poor/intermittent/splayed), hesitancy, post micturition dribble, urinary retention,
nocturia, double voiding
-
Daytime frequency, dysuria, urgency, strangury
Incontinence (stress/urge/continuous), enuresis
Haematuria
Renal/ureteric colic
Knowledge of the clinical presentation, investigations and management of the
following scenarios:
-
Patient with haematuria (either frank or microscopic, either painful or painless)
Patient with scrotal swelling (acute and chronic)
Patient with poor urinary stream (voiding and bladder storage problems)
Patient with renal/ureteric colic
Patient with urinary tract infection
Patient with bladder cancer
Patient with prostatic carcinoma
Patient with renal carcinoma
Patient with testicular cancer
Examination Skills:
-
Be able to perform a full abdominal examination including;
Theoretical knowledge of normal and abnormal findings on rectal exam
Be able to Ballott kidneys
Be able to describe the difference on clinical examination between palpable kidneys,
liver, spleen
Be able to percuss a bladder to determine if it is full or not
Testis examination
Scenario Based Learning Objectives
Patient with haematuria
-
Outline the common causes of haematuria
Outline the first line investigations of a patient with haematuria
Outline the second line investigations based on the common first line findings
Discuss the presentation and management of haematuria in relation to trauma to the
kidney, ureter, bladder and urethra.
Describe the presentation and treatment of patient with infections in the GU tract
Describe the aetiology, presentation and management of renal calculi
67 | Clinical Attachments
Patient with poor urinary stream
-
Describe the presentation of bladder outlet obstruction, the common causes and the
relevant questions
Describe how you would decide if intervention is required
Say how you assess the need for intervention
Outline the common treatment modalities for the common causes
Describe the management of benign prostatic hyperplasia
Describe the management of urethral stricture
Describe the complications of TURP
A patient with acute scrotal pain
-
Provide a differential diagnosis of acute scrotal pain
Discuss the presentation, diagnosis and management of torsion of the testis
Describe the indications for exploration of the testis
Patient with renal/ureteric colic
-
Provide a differential diagnosis for acute flank/abdominal pain
Discuss the presentation, diagnosis and management options for renal/ureteric
calculi
Describe a management plan for the investigation of recurrent renal calculi +
complications
A patient with a GU malignancy
-
Describe the presentation and management of renal cell carcinoma,
Describe the presentation and management of transitional cell carcinoma of the
bladder
Describe the presentation and management of carcinoma of the prostrate
Describe to presentation and management of testicular carcinoma
Patient with scrotal swelling




Discuss the differential diagnosis of a testicular swelling
Describe how you would distinguish a scrotal swelling from a hernia
Describe the role of transillumination
Distinguish between an epididymal and testis swelling
A patient with a kidney (and pancreas) transplant





List the indications for kidney transplantation
Indicate how you would decide on the suitability of a donor for organ transplantation
Describe the usual anatomical positions for renal transplant in children and adults
Outline the criteria for establishing death for the purposes of organ donation.
Broadly list the medications used in immunosuppression for transplantation
68 | Clinical Attachments
All students should have seen during their rotation the following:
CAPD Tenchkoff dialysis catheter
Ileal Conduit
Percutaneous Nephrostomy tube
Testicular tumour/exploration
KUB
Three way urethral catheter + Irrigation
TURP
Arteriovenous dialysis fistula
Nephrectomy incision
Hydrocoele
IVP
Cystoscopy
Suprapubic catheter
All students by the end of the rotation should be able to describe the mechanism of
action and role of the following drugs used in Urology;
-
Alpha antagonists
LHRH analogues
Antiandrogens
Anticholinergics
Genitourinary antibiotics
All students by the end of final medical years should have developed the following
skills:-
The ability to pass a urinary catheter
The ability to assess the prostate on rectal examination
The ability to interpret an IVU, KUB, renal isotope scan, and CT
The ability to interpret renal function from blood and urinary electrolyte results
The ability to examine the abdomen and identify an abdominal mass
The ability to examine the scrotum and diagnose the cause of testicular swellings
Management and Professional Behaviour
- Full attendance at weekly schedule; Ward round each morning at 7.30am
Bennett’s ward
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
69 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
Vascular surgery
Mr. Martin Feeley, Prof. Sean Tierney, Ms Bridget Egan
AMNCH
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
- Natural history, and general and specific treatment of vascular surgical conditions
- Pathophysiology of vascular surgical conditions, and the response of the body to the
various vascular surgery problems
- Non-invasive and invasive vascular diagnostic tests and it's most common
applications.
- Diagnosis and treatment of peripheral arterial and venous disease.
- Endovascular therapy
- Specific Knowledge The student will be expected to demonstrate a fundamental
knowledge and understanding of the following areas and disease processes
- Arterial Disease: Atherosclerosis, Non-atherosclerotic arterial disease, Carotid
artery disease, Acute lower limb ischaemia, Chronic / Critical lower limb
ischaemia, Abdominal, Aortic Aneurysm, Arterial Aneurysmal disease,
Endovascular Surgery
- Venous & Lymphatic Disease:, Varicose veins, Superficial Thrombophlebitis,
Deep venous thrombosis, Chronic venous insufficiency, Lymphoedema
Technical Skills/Procedures
The student should be able to do the following to the satisfaction of his/her supervisor(s):
- Take a relevant history.
- Perform an acceptable physical exam concentrating on the relevant areas, including
establishing an Ankle Brachial Pressure Index (ABPI)
- Arrive at an appropriate differential diagnosis.
- Attendance in theatre
- Accsess to our web page www.perfuse.net. This web page is designed as an
educational resource for students, trainees and patients of our unit.
Management and Professional Behaviour
- Full attendance at weekly schedule;
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include
 Review student log book
 Feedback on level of integration with the team and patients
 Formal assessment as per medical school
 Presentation of cases
70 | Clinical Attachments
SPECIALTY:
CONSULTANT:
HOSPITAL:
Vascular surgery
Mr Moore, Mr Madhavan, Mr O’Neill
SJH
OBJECTIVES OF ATTACHMENT
During this attachment a student is expected to
Know
-
-
-
-
-
To become familiar with the recognition, natural history, and general and specific
treatment of those vascular surgical conditions that one would expect to encounter in
a general surgery practice in a community lacking the immediate availability of a
vascular surgeon.
To familiarize oneself with the pathophysiology of vascular surgical conditions, and
the response of a patient to the various vascular surgery problems
To gain a broad understanding of common elective and emergent vascular conditions
in the following areas:
o Carotid arterial occlusive disease.
o Aortoiliac occlusive disease.
o Femoral popliteal arterial occlusive disease.
o Aneurysmal disease.
o Venous disease.
To gain a broad understanding of non-invasive vascular diagnosis and it's most
common applications. To gain a broad understanding of the diagnosis of peripheral
arterial and venous disease.
To participate fully in the ambulatory and inpatient settings including clinic, wards
and the operating room.
To understand the role of endovascular therapy versus open surgical management:
the potential advantages and disadvantages of each option.
Technical Skills/Procedures
The student should be able to do the following to the satisfaction of his/her supervisor(s):
-
Take a relevant history.
Perform an acceptable physical exam concentrating on the relevant areas, including
establishing an Ankle Brachial Pressure Index (ABPI)
Arrive at an appropriate differential diagnosis.
Scenario Based Learning Objectives.
Patient with an ulcer
-
Describe the ulcer and findings from the peripheral vascular exam
Provide a differential diagnosis for different types of ulceration
Distinguish arterial from venous from mixed aetiology ulcers
Describe how you would decide if intervention is required
Say how you assess the need for intervention
Outline the common treatment modalities for the common causes
71 | Clinical Attachments
Patient with an aortic aneurysm
-
Describe the physical findings from the peripheral vascular exam
List the risk factors for development of AAA
Describe the common presentations of AAA: i.e. following rupture or screening
Say how you would investigate a patient suspected of having a ruptured AAA
Describe how you would decide if intervention is required in the elective setting
Say how you assess the need for intervention
Outline the common treatment modalities (endovascular vs open)
Make reference to the relevant clinical trials
Patient with carotid artery disease
-
Describe the common clinical presentations of carotid artery disease
Distinguish the importance of asymptomatic versus symptomatic disease
Describe the physical findings from the peripheral vascular exam
List the risk factors for development of carotid artery disease
Say how you would investigate a patient suspected of having carotid artery disease
Describe how you would decide if intervention is required in the emergency and
elective setting
Say how you assess the need for intervention
Outline the common treatment modalities (endovascular vs open)
Make reference to the relevant clinical trials
Patient with acute ischaemia
-
Describe the common clinical symptoms of acute ischaemia
Describe the physical findings from the peripheral vascular exam
List the risk factors for development of acute ischaemia
Say how you would investigate a patient suspected of having an acutely ischaemic
limb
Describe how you would decide if intervention is required in the emergency and
elective setting
Outline the common treatment modalities (endovascular vs open)
Patient with chronic peripheral vascular disease
-
Describe the common clinical symptoms of chronic ischaemia
Describe the physical findings from the peripheral vascular exam
List the risk factors for development of chronic peripheral vascular disease
Distinguish acute from chronic ischaemia
Say how you would investigate a patient suspected of having peripheral vascular
disease
Describe how you would decide if intervention is required in the elective setting
Understand the difference between life-limiting claudication and critical ischaemia
(either rest pain or tissue loss) as indications for intervention
Outline the common treatment modalities (endovascular vs open) Make reference to
the relevant clinical trials
72 | Clinical Attachments
All students should have seen during their rotation the following:
-
Various types of ulcers
Four-layered compression dressing
Arteriovenous fistula
Carotid endarterectomy
Endovascular procedures including EVAR
Varicose veins
Aortic aneurysm
Doppler assessment of veins
CT angiograms
Chronic ischaemia
Management and Professional Behaviour
- Full attendance at weekly schedule; Ward round each morning at 7.30am Sir
Patrick Dun’s ward
- Continuity of care of at least 2 patients/week
- Attendance at multidisciplinary team decision meetings
- Dignity in dealing with patients, family & staff
- Understand ethical principles relating to consent, decision-making
- Development of communication skills
At the end of this attachment the assessment format will include




Review student log book
Feedback on level of integration with the team and patients
Formal assessment as per medical school
Presentation of cases
73 | Clinical Attachments
Department of Surgery
Staff/Contact Numbers
St.James’s Hospital
Professor John V. Reynolds
Chair of Surgery
Ms Liz Connolly
Senior Lecturer/Consultant
EMConnolly@stjames.ie
Mr. N Ravi
Senior Lecturer/Consultant
ravin@tcd.ie
Mr John Connelly
Lecturer
John_conneelly@mac.com
Ms Clare Donohue
Lecturer
donohoe.claire@gmail.com
Ms. Sarah Picardo
Lecturer
sarahpicardo@gmail.com
Ms Clare Martin
Clinical Skills Tutor
martinc4@tcd.ie
Ms Triona Flavin
Clinical Skills Tutor
tflavin@tcd.ie
Ms Siobhan Ryan
Executive Officer
siobhan.ryan@tcd.ie
1 8962189
Professor Kevin Conlon
Chair of Surgery
profsurg@tcd.ie
Mr Paul Ridgway
Senior Lecturer/ Consultant
ridgwayp@tcd.ie
Mr. Omer El Tayeb
Lecturer in Surgery
01 89683711
Ms. Anne Barrett
Administrator AMNCH
01 4144017
Ms. Breda Devitt
Administration AMNCH
01 4142211
Ms Phillippa Marks
Clinical Skills Tutor
01 8961475
Ms Marie Morris
Clinical Skills Co-ordinator
& Tutor
Executive Officer
01 8962910
AMiNCH
Ms. Alison Cowie
74 | Clinical Attachments
01 8963719
Appendix 1: Specialist History Templates
REHABIILITATION EVALUATION OF A PATIENT WITH NEUROLOGICAL
IMPAIRMENTS.
History.
History of presenting complaint.
Past Medical History. ( additional impairments, co- morbidities )
Family History.
Social History. Home, accessibility, family, dependents, community, family support, work,
school, recreation.
Review of systems.
Central nervous.
Cardiovascular
Gastrointestinal
Musculoskeletal
Respiratory
Circulatory
Genitourinary
Psychological
Evaluation of functional deficits. (activity limitations)
Premorbid functional status
Current functional status
Neurological Examination in relation to Function.
Neurological Exam.
Functional correlate
Mini mental status.
Global cognitive orientation and function.
Frontal lobe syndromes.
Speech and Language.
Cranial nerves.
1
11
111, 1V, V1
V
V11
V111
1X, X, X11.
X1
Manual muscle testing.
Taste smell
Vision, visual fields
diplopia
facial sensation, mastication
facial expression, pocketing of food.
hearing.
swallowing.
shoulder shrug, sternocleidomastoid.
Grade 1-5
Sensation. light touch, pinprick, temperature, proprioception, stereognosis.
Reflexes
Balance
75 | Clinical Attachments
Co-ordination.
Gait.
REHABILITATION ASSESSMENT AND INTERVENTIONS
Impairments.
Activity limitations.
Participation Limitations.
Rehabilitation utilizes a holistic and interdisciplinary team approach to maximize
outcomes in patients with impairments, activity and participation limitations
associated with neurological disorders.
Rehabilitation team.
Physical and Rehabilitation Medicine physician.
Rehabilitation Nursing.
Physiotherapy
Occupational therapy
Speech and Language therapy
Audiology
Psychology
Recreational
Family
Orthotics
Prosthetics
Rehabilitation Outcomes.
1. Preventing secondary complications that will add to impairments
2. Maximizing functional independence (activity)
3. Promoting community reintegration and return to work, social and recreational activities.
(participation)
4. Promoting Quality of life
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History taking in Surgical Patients
Most important part of the decision making tree
This should follow the following pattern
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Demographics – name, sex, age, race and occupation
Presenting complaint : duration, onset, severity, list multiple complaints in order of
severity
History of the presenting Complaint(s): Chronological account of the development of
the complaint(s). Exact dates. Clarification of history if necessary. Remaining
questions about the abnormal system
Past medical / surgical history: Diabetes, asthma, hypertension, tuberculosis,
rheumatic fever, bleeding tendencies, ischaemic heart disease, past surgical procedures,
date of procedures, accidents.
Drug history: Steroids, anticoagulants, monoamine oxidase inhibitors, insulin, OCP,
anti-hypertensive, bronchodilators, oral hypoglycemics ect.
Allergy : Drugs, dressings, food etc
Family History : health of close family, deaths, malignancies, similar complaints
Social history : smoking, alcohol, accommodation, support, occupation (exposure to
chemicals or disease), marital status, hobbies, travel abroad
Systemic Review : Cardiovascular, Respiratory, Gastrointestinal, Genitourinary,
Musculoskeletal, Nervous System, breast, vascular
Pain history: site, radiation, referred pain, character or nature, severity, mode of onset /
duration, pattern, periodicity and progress, aggravating and relieving factors
Physical examination of surgical patient
General physical examination includes vital observations (Pulse, BP, Temperature and
Respiratory rate), weight loss, anaemia, jaundice and obvious deformity.
Systematic examination including cardiovascular, respiratory and neurological. This
provides risk stratification for these patients if they require surgical intervention.
Abdominal examination including all quadrants assessment
Other examinations such as: neck/thyroid, breast, groin/inguinal hernia, vascular, lumps and
ulcers.
Each system examination in sequence of inspection, palpation, percussion and auscultation.
Repetition of each examination with standard bed side manners such as introduction to the
patient, privacy, anticipatory warnings/explanations, chaperone and gratitude at the end of
examination.
77 | Clinical Attachments
Appendix 2: Principles of Surgical Investigation and Peri-operative
Care
Investigation for surgical patients
Base line tests
 Interpretations of Full blood count such as haemoglobin, differential blood and
platelet count.
 Electrolytes& Urea and its interpretation.
 What is the importance of swab for culture and sensitivity and blood cultures?
 Urinalysis and its interpretation.
 Liver function tests with obstructive and non obstructive patterns.
 Nutritional assessment such anthropological and biochemical measurements
 Interpretation of chest x-rays and plain abdominal films.
Specific tests
 Indications for contrast studies such as barium swallow, barium meal, intravenous
urography, angiogram, etc
 Advantages of Imaging with U/S, C/T, MRI, PET scanning, fluoroscopic studies and
radioisotope studies.
 Benefits of endoscopic assessment such as gastroscopy, colonoscopy and
cystoscopy.
 Obtaining a histological diagnosis by fine needle aspiration, trucut biopsy or open
biopsy.
Preoperative preparation for surgical patients
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To ensure operation is performed with minimal risk and maximal benefit, in a cost
effective manner
Adequate history and physical examination
Respiratory, cardiovascular, metabolic and nutritional risks assessments
Vital systems optimisation such as
o Improving lung capacities by Inhalers, bronchodilators, steroids and chest
physiotherapy.
o Effective blood pressure control thus reducing cardiac or cerebral events,
treating arrhythmia such as atrial fibrillation to inhibit peripheral arterial
embolisation.
Treatment of active sepsis with appropriate antibiotics.
Reducing risk of aspiration pneumonia by nasogastric tube insertion,
Intravenous fluids and urine output monitoring.
Glycaemic control by sliding scale insulin.
Prophylactic anticoagulation according to the risk group category.
Improving nutritional status by parental or enteral nutrition. Which is more
beneficial and why?
Assessment of patients for in-patient or out-patient procedure – surgical category
and ASA classification
What is informed consent and its implications?
78 | Clinical Attachments
Postoperative care of surgical patients
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To enhance the patients overall recovery and decrease the incidence of
complications
Monitoring of vital observations.
Fluid and electrolyte balancing.
Blood replacement rationale.
Adequate pain control-what are the means of achieving this and the main benefits to
the patient.
Monitoring of urine output and central venous pressure-how do we do it.
Respiratory complications including atelactasis, lobar pneumonia and blood oxygen
desaturations. How do we manage these
Cardiac complications including dysrhythmias, myocardial infarction, ventricular
failure and hypertension - 2° to pain or hypoxia
Postoperative fever: atelactasis, pneumonia, UTI, septic and non-septic phlebitis,
wound infection, drug allergies, other deep infection. How do we manage these
Chest tube insertions for pneumothorax and haemothorax. Which is the best
position for insertion? What is Tension Pneumothorax and how should this be
tackled.
What is deep venous thrombosis and what way is this treated
Advantages of early ambulation
Surgical infections
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Know types of operative wounds such as clean, contaminated and infected.
Bacterial load of gut organisms-which antibiotics are effective against gram
negatives cocci and bacteroids.
Abdominal wound dehiscence. What are the signs of this condition and how is this
treated.
Necrotising fasciitis
Risk of superadded fungal infection in patients who are on multiple antibiotics for
long periods.
Is there a role for prophylactic antibiotics to reduce the surgical infections?
Multidisciplinary team management
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What are the benefits of this approach for patients as well as surgeon?
For example
o Evidence based medicine can be practiced within each surgical speciality.
o Optimal therapy can be planned for cancerous and complex diseases.
o Patient satisfaction is high.
79 | Clinical Attachments
Appendix 3: Weekly Timetable (PHOTOCOPY FOR EACH
TEAM)
MAJOR TEAM ACTIVITIES IN A TYPICAL WEEK
Team:_______________________________________
Consultant:___________________________________
MON
Outpatient
Session
Consultant
Rounds
General
Rounds
Clinical
Conference/t
utorial
On take for
admissions
Theatre lists
Investigative
procedures
e.g. skin
biopsy
Other
Activities
80 | Clinical Attachments
TUES
WED
THUR
FRI